S2642 A Novel Use of Transcatheter Aortic Valve Replacement for Aortic Regurgitation in End-Stage Liver Disease

Abstract

INTRODUCTION: The combination of severe aortic regurgitation (AR), end-stage liver disease (ESLD), and end-stage renal disease (ESRD) carries significant morbidity and mortality. ESLD induces a hyperdynamic circulation characterized by peripheral vasodilation, low intravascular volume, and impaired contractility, resulting in poor cardiac reserve. As such, treatment options for valvular abnormalities such as AR in the setting of ESLD and ESRD remain challenging. While transcatheter aortic valve replacement (TAVR) for treatment of severe aortic stenosis (AS) is well established, minimally-invasive treatment options for AR are limited. We present a case of severe AR in a patient with ESLD and ESRD treated via expanded-access TAVR, hence allowing the patient to maintain transplant candidacy. CASE DESCRIPTION/METHODS: A 48 y/o male with history of alcohol-related ESLD and ESRD was referred for evaluation of simultaneous liver and kidney transplant. Initial evaluation revealed him to be Child Turcotte Pugh class C with a MELD-Na of 33. During pre-transplant evaluation, a transthoracic echocardiogram revealed a mobile hypoechoic mass near the non-coronary leaflet, with resultant severe eccentric AR. Transesophageal echocardiogram confirmed a 10 × 4.5mm mobile vegetation on the left coronary cusp (AR PISA radius: 0.81cm and AR PISA volume: 52.29ml). Upon further workup, blood cultures were found to be positive for Streptococcus, likely disseminated from his tunneled internal jugular dialysis catheter. The patient was initiated on 6 weeks of IV Cefazolin with subsequent replacement of the hemodialysis catheter. The presence of severe AR was deemed prohibitive for transplantation, and he was assessed to be too high-risk for open cardiac valve repair. However, after presentation at a multi-disciplinary structural heart disease case conference, the treating team recommended an expanded access, compassionate use TAVR, usually performed for AS. FDA and Henry Ford IRB approval was obtained with completion of TAVR via transfemoral approach and resulting reduction of his severe AR to trivial AR. This novel technique has allowed the patient to potentially be re-listed for liver and kidney transplant. DISCUSSION: Our case displays the use of a multidisciplinary approach to determining a novel and minimally-invasive approach for repair of AR in a high-risk patient. Furthermore, correction of the patient’s AR has allowed for preservation of his transplant candidacy.