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Transfemoral transcatheter aortic valve implantation in a patient with a severe aortic stenosis and cardiogenic shock requiring intra-aortic balloon pump support.

Chodór P, Wilczek K, Przybylski R, Świątkowski A, Głowacki J, Kalarus Z, Zembala M - Postepy Kardiol Interwencyjnej (2015)

Bottom Line: The following paper presents a patient with severe aortic stenosis and severely reduced left ventricular ejection fraction with intra-aortic balloon pump counterpulsation support, who underwent transfemoral aortic valve implantation of a CoreValve prosthesis.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia in Katowice, Silesian Center for Heart Diseases in Zabrze, Poland.

ABSTRACT
The following paper presents a patient with severe aortic stenosis and severely reduced left ventricular ejection fraction with intra-aortic balloon pump counterpulsation support, who underwent transfemoral aortic valve implantation of a CoreValve prosthesis.

No MeSH data available.


Related in: MedlinePlus

Aortography – aortic valve implantation during ventricular fibrillation
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Figure 0001: Aortography – aortic valve implantation during ventricular fibrillation

Mentions: A 79-year-old male was admitted to the cardiac care unit (CCU) with symptoms of acute heart failure (HF) in the course of severe AS, evolving to pulmonary oedema and CS. Due to the rapid progression of HF, in addition to dopamine infusion, an IABP support was started. Echocardiography (ECHO) demonstrated the following: left ventricle (LV) 6.6/5.6 cm, ascending aorta (Ao) 4.1 cm, left atrium (LA) 5.2 cm, left ventricular ejection fraction (LVEF) of 10% on admission and 21% after an IABP introduction, and moderate/severe mitral regurgitation (MR). Peak and mean AV gradient was 137 mm Hg and 65 mm Hg, respectively, with a mild aortic regurgitation (AR). Calcifications were found in the AV. The AV annulus was 2.5 cm. Moderate tricuspid regurgitation (TR) was present with a right ventricle systolic pressure (RVSP) of 70 mm Hg. It was decided to perform an emergency balloon aortic valvuloplasty (BAV). During the BAV, the IABP was set at a 1: 1 assist ratio, but it was turned off during the RV rapid pacing (RP). After the BAV the mean AV gradient decreased from 57 mm Hg to 27 mm Hg and the AV area increased from 0.35 cm2 to 0.7 cm2. The baseline NT pro-BNP was over 35000 pg/ml. Substantial improvement of the patient's state allowed reduction of catecholamines and weaning off the IABP on the 16th day after admission. However, 4 days later a re-introduction of IABP was required due to haemodynamic deterioration. Coronary angiography revealed normal coronary arteries. The computed tomography (CT) angiography parameters were as follows: annulus diameter 2.6 cm, aortic root 3.1 cm, sinotubular junction 2.7 cm, ascending aorta 4.6 cm; femoral and subclavian arteries > 0.6 cm. The Logistic Euroscore and STS score were 30% and 12%, respectively. Due to the high risk, the patient was considered a candidate for TAVI. The patient displayed symptoms of infection, and as a result Acinetobacter Baumani was isolated from blood cultures. The infection was treated with antibiotics according to the antibiogram. Despite the initial improvement, there was a recurrence of fever. Fungal infection was suspected and so caspofungin was started. The TAVI procedure had to be postponed several times due to observed symptoms of infection. The medical team decided to perform TAVI because they were convinced that further delay of the intervention would result in subsequent deterioration of the patient's condition and ultimately death. The TAVI was performed 3 weeks after the IABP re-implantation when the patient had been without fever for 5 consecutive days and a significant drop of inflammatory parameters was recorded. Blood cultures, however, were still positive on the day prior to the procedure. The femoral approach was chosen. A surgical exposure and cut-down of the artery was applied in deep sedation and local anaesthesia. The patient was IABP-dependent throughout the procedure. The patient's blood pressure was 90/41 mean 64 mm Hg with IABP support. The BAV was performed on RP at a rate of 190 min−1 and on IABP switched to ‘standby’ mode. Immediately after BAV no increase in the AR was detected on ECHO. A MCV size 29 was chosen. Frequent contrast injection not only made positioning of the valve easier but also ensured that no significant AR was present. During the implantation when 2/3 of MCV was deployed and the valve started to function, ventricular fibrillation occurred. After checking the position of the valve, the implantation was completed promptly and cardiac massage was started followed by five defibrillation shocks delivered with sinus rhythm restoration (Figure 1). The patient was intubated and ventilated. The procedure was completed under general anaesthesia.


Transfemoral transcatheter aortic valve implantation in a patient with a severe aortic stenosis and cardiogenic shock requiring intra-aortic balloon pump support.

Chodór P, Wilczek K, Przybylski R, Świątkowski A, Głowacki J, Kalarus Z, Zembala M - Postepy Kardiol Interwencyjnej (2015)

Aortography – aortic valve implantation during ventricular fibrillation
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4372634&req=5

Figure 0001: Aortography – aortic valve implantation during ventricular fibrillation
Mentions: A 79-year-old male was admitted to the cardiac care unit (CCU) with symptoms of acute heart failure (HF) in the course of severe AS, evolving to pulmonary oedema and CS. Due to the rapid progression of HF, in addition to dopamine infusion, an IABP support was started. Echocardiography (ECHO) demonstrated the following: left ventricle (LV) 6.6/5.6 cm, ascending aorta (Ao) 4.1 cm, left atrium (LA) 5.2 cm, left ventricular ejection fraction (LVEF) of 10% on admission and 21% after an IABP introduction, and moderate/severe mitral regurgitation (MR). Peak and mean AV gradient was 137 mm Hg and 65 mm Hg, respectively, with a mild aortic regurgitation (AR). Calcifications were found in the AV. The AV annulus was 2.5 cm. Moderate tricuspid regurgitation (TR) was present with a right ventricle systolic pressure (RVSP) of 70 mm Hg. It was decided to perform an emergency balloon aortic valvuloplasty (BAV). During the BAV, the IABP was set at a 1: 1 assist ratio, but it was turned off during the RV rapid pacing (RP). After the BAV the mean AV gradient decreased from 57 mm Hg to 27 mm Hg and the AV area increased from 0.35 cm2 to 0.7 cm2. The baseline NT pro-BNP was over 35000 pg/ml. Substantial improvement of the patient's state allowed reduction of catecholamines and weaning off the IABP on the 16th day after admission. However, 4 days later a re-introduction of IABP was required due to haemodynamic deterioration. Coronary angiography revealed normal coronary arteries. The computed tomography (CT) angiography parameters were as follows: annulus diameter 2.6 cm, aortic root 3.1 cm, sinotubular junction 2.7 cm, ascending aorta 4.6 cm; femoral and subclavian arteries > 0.6 cm. The Logistic Euroscore and STS score were 30% and 12%, respectively. Due to the high risk, the patient was considered a candidate for TAVI. The patient displayed symptoms of infection, and as a result Acinetobacter Baumani was isolated from blood cultures. The infection was treated with antibiotics according to the antibiogram. Despite the initial improvement, there was a recurrence of fever. Fungal infection was suspected and so caspofungin was started. The TAVI procedure had to be postponed several times due to observed symptoms of infection. The medical team decided to perform TAVI because they were convinced that further delay of the intervention would result in subsequent deterioration of the patient's condition and ultimately death. The TAVI was performed 3 weeks after the IABP re-implantation when the patient had been without fever for 5 consecutive days and a significant drop of inflammatory parameters was recorded. Blood cultures, however, were still positive on the day prior to the procedure. The femoral approach was chosen. A surgical exposure and cut-down of the artery was applied in deep sedation and local anaesthesia. The patient was IABP-dependent throughout the procedure. The patient's blood pressure was 90/41 mean 64 mm Hg with IABP support. The BAV was performed on RP at a rate of 190 min−1 and on IABP switched to ‘standby’ mode. Immediately after BAV no increase in the AR was detected on ECHO. A MCV size 29 was chosen. Frequent contrast injection not only made positioning of the valve easier but also ensured that no significant AR was present. During the implantation when 2/3 of MCV was deployed and the valve started to function, ventricular fibrillation occurred. After checking the position of the valve, the implantation was completed promptly and cardiac massage was started followed by five defibrillation shocks delivered with sinus rhythm restoration (Figure 1). The patient was intubated and ventilated. The procedure was completed under general anaesthesia.

Bottom Line: The following paper presents a patient with severe aortic stenosis and severely reduced left ventricular ejection fraction with intra-aortic balloon pump counterpulsation support, who underwent transfemoral aortic valve implantation of a CoreValve prosthesis.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia in Katowice, Silesian Center for Heart Diseases in Zabrze, Poland.

ABSTRACT
The following paper presents a patient with severe aortic stenosis and severely reduced left ventricular ejection fraction with intra-aortic balloon pump counterpulsation support, who underwent transfemoral aortic valve implantation of a CoreValve prosthesis.

No MeSH data available.


Related in: MedlinePlus