Simultaneous Transcatheter Aortic Valve Implantation and Drive-By Endovascular Aortic Aneurysm Repair with the Lotus Valve System

Abstract

A 79-year-old man with severe, but stable, long-standing chronic obstructive pulmonary disease (COPD; FEV1 22%) was recently found to have a 6cm infrarenal fusiform abdominal aortic aneurysm (AAA) (figure A). He presented with progressively worsening breathlessness, disproportionate to his COPD, and echocardiography demonstrated critical calcified aortic stenosis (AS; mean gradient 93mmHg, aortic valve area 0.6cm2) with normal ejection fraction. He was deemed to be at prohibitive surgical risk by the Heart Team and therefore simultaneous endovascular aneurysm repair (EVAR) and transcatheter aortic valve replacement (TAVR) was recommended. CT revealed good calibre ileofemoral arteries and aortic annular dimensions suitable for a 25mm Lotus device (Boston Scientific, MA). Due to severe COPD, the procedure was performed under spontaneous ventilation general anaesthesia with laryngeal mask. The procedural strategy was to perform balloon valvuloplasty first (12x40mm Armada balloon), followed by EVAR (Cook Zenith Endovascular graft, figure B) and then TAVR. The 25mm Lotus valve adopted a barrel-shape suggestive of an undersised valve (figure C), so the decision was to replace it with a 27mm valve. The Lotus delivery system passed easily through the EVAR stents and deployment was successful. Post procedural transthoracic echo revealed no paravalvular regurgitation. Severe AS and AAA are increasingly prevalent and management of both simultaneously increases the complexity and risk of the procedure. We report here for the first time a successful simultaneous EVAR/TAVR procedure using the fully repositionable and retrievable Lotus Valve System.