Tesi etd-01102022-170327
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Tipo di tesi
Master di Secondo Livello
Autore
GROTTI, SIMONE
Indirizzo email
grotti.simone@gmail.com
URN
etd-01102022-170327
Titolo
Valve-in-Valve transcatheter aortic valve implantation: combined use of Chimney Technique and Balloon Valve Fracture to prevent coronary obstruction and prosthesis-patient mismatch
Struttura
Istituto di Scienze della Vita
Corso di studi
Corsi Alta Formazione - PERCUTANEOUS INTERVENTIONAL TREATMENT OF STRUCTURAL HEART DISEASES
Commissione
relatore Prof. BERTI, SERGIO
Membro Prof. PASSINO, CLAUDIO
Membro Prof. PASSINO, CLAUDIO
Parole chiave
- coronary obstruction
- prosthesis-patient mismatch
- TAVI
- valve-in-valve
Data inizio appello
21/01/2022;
Disponibilità
completa
Riassunto analitico
In the last decades, the use of bioprosthetic valves for aortic valve replacement has significantly increased. To date, clinically relevant deterioration of bioprostheses occurs typically at 10-15 years after valve implantation. Transcatheter aortic valve implantation (TAVI) for valve-in-valve (ViV) intervention could represent an important opportunity for this group of patients due to its mini-invasive modality, and its use in this setting is expected to grow significantly. Nonetheless, in comparison to TAVI for native aortic valve disease, patients undergoing ViV procedures show lower device success rates with higher residual transaortic gradients and higher intraprocedural complications. Among those complications, coronary obstruction stands out as one of the most feared during aortic ViV.
We describe the case of a 79-year-old woman with severe bioprosthetic aortic valve stenosis (Crown PRT 19), narrow sinuses of Valsalva and low coronary heights, who was referred at our institution for transcatheter VIV implantation. Given the high risk of residual gradient and coronary obstruction after ViV intervention, we planned to perform also Balloon Valve Fracture and Chimney stenting techniques.
A supra-annular self-expandable valve (Medtronic EvolutR 23 mm) was selected for the procedure. Before valve implantation, right and left coronary artery were engaged and wired, then two stents were parked in the two vessels. The guiding catheters were positioned just inside the coronary ostia. Then, the valve was successfully deployed with standard technique, using the bioprosthesis stent as radio-opaque marker for the implantation. No paravalvular leaks were seen, however a significant transvalvular gradient was present. For valve fracture, we used a non-compliant balloon with a diameter 1 mm greater than the bioprosthesis (20 mm), that was inflated at high pressures, obtaining the ring fracture. After this, we deployed the two coronary stents from the proximal tract of right coronary artery and left anterior descending artery to the aortic sinotubular junction. The final result showed no transvalvular gradient neither paravalvular leaks, while both stents appeared well expanded and coronary arteries well perfused.
ViV is a complex intervention, with reduced procedural success compared with TAVI for native valves, and potential life-threatening complications. A thorough planning with computed tomography imaging is paramount to prevent complications and obtain a positive outcome. As appropriate, the team should consider both Balloon Valve Fracture and Chimney Stenting technique to achieve the best short- and long-term result, reducing the risk of residual trans-valvular gradient and ensuring optimal coronary perfusion.
We describe the case of a 79-year-old woman with severe bioprosthetic aortic valve stenosis (Crown PRT 19), narrow sinuses of Valsalva and low coronary heights, who was referred at our institution for transcatheter VIV implantation. Given the high risk of residual gradient and coronary obstruction after ViV intervention, we planned to perform also Balloon Valve Fracture and Chimney stenting techniques.
A supra-annular self-expandable valve (Medtronic EvolutR 23 mm) was selected for the procedure. Before valve implantation, right and left coronary artery were engaged and wired, then two stents were parked in the two vessels. The guiding catheters were positioned just inside the coronary ostia. Then, the valve was successfully deployed with standard technique, using the bioprosthesis stent as radio-opaque marker for the implantation. No paravalvular leaks were seen, however a significant transvalvular gradient was present. For valve fracture, we used a non-compliant balloon with a diameter 1 mm greater than the bioprosthesis (20 mm), that was inflated at high pressures, obtaining the ring fracture. After this, we deployed the two coronary stents from the proximal tract of right coronary artery and left anterior descending artery to the aortic sinotubular junction. The final result showed no transvalvular gradient neither paravalvular leaks, while both stents appeared well expanded and coronary arteries well perfused.
ViV is a complex intervention, with reduced procedural success compared with TAVI for native valves, and potential life-threatening complications. A thorough planning with computed tomography imaging is paramount to prevent complications and obtain a positive outcome. As appropriate, the team should consider both Balloon Valve Fracture and Chimney Stenting technique to achieve the best short- and long-term result, reducing the risk of residual trans-valvular gradient and ensuring optimal coronary perfusion.
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