Percutaneous aortic balloon valvuloplasty under transesophageal echocardiographic guidance

Abstract

The patient was a 56-year-old man with aortic stenosis who presented for aortic valve replacement. He had previously undergone coronary artery bypass grafting and had received extensive external beam radiation to his left chest as treatment for lymphoma. His preoperative peak aortic valve gradient as measured by transthoracic echocardiography was 55 mmHg. The patient had a history of syncope, angina, and congestive heart failure. Following induction of anesthesia, a biplane transesophageal echocardiography probe was inserted without difficulty. Initial findings included a peak pressure gradient across the aorticvalve of 58 mmHg without evidence of aortic insufficiency. Median sternotomy was performed and significant hemorrhage noted resulting from transection of the innominate vein. The patient was placed on partial femoral bypass and the transsected vein repaired, but further dissection resulted in disruption of the right ventricular wall and massive hemorrhage. After this bleeding was controlled, the surgeons decided further dissection would be potentially fatal. Because of the severity of the patient’s aortic stenosis, however, it was believed that intervention was necessary. Percutaneous aortic valvuloplasty was undertaken in the operating room by a cardiologist using a left femoral artery approach. Initially, a guidewire was passed across the aortic valve with transesophageal echocardio