Feasibility of transapical aortic valve implantation guided by intracardiac ultrasound without angiography

Abstract

CLINICAL SUMMARY A 78-year-old man with symptomatic aortic stenosis was evaluated for TAVI. Concomitant comorbidities were coronary artery sclerosis, peripheral vascular disease, bilateral carotid stenosis, and pulmonary hypertension (50 mm Hg). He also had alcohol-related liver cirrhosis (Child score A) complicated by grade 2 esophageal varices (treated with propranolol) and a platelet count chronically less than 80 3 10/dL. The echocardiogram showed severe aortic stenosis (orifice area, 0.55 cm) with transvalvular peak and mean gradients of 68 mm Hg and 38 mm Hg, respectively, moderate left ventricular hypertrophy, and preserved function (left ventricular ejection fraction, 60%). The logistic EuroSCORE was 18%. However, the EuroSCORE does not take into consideration the liver cirrhosis, which is an important risk factor negatively influencing the outcome of highrisk patients undergoing standard cardiac surgery. Therefore, we offered the patient a less-invasive procedure, and a transapical TAVI was scheduled. Computed tomography scan measurements showed the following: aortic annulus 1⁄4 24 mm diameter; distances between the annulus and the coronary ostia 1⁄4 10.5 mm (left) and 11 mm (right); and C-arm fluoroscopy pre-orientation 1⁄4 18 degrees left (lateral position) and 11 degrees cranial. Before the procedure, a gastroscopy (performed with care under general anesthesia) confirmed the presence of esophageal varices contraindicating TEE use.