701 ECMO assistance during TAVI in high-risk patient with recent COVID-19 pneumonia

Methods and results A 87 years old woman, with history of dyslipidemia and permanent Atrial Fibrillation, already undergone full SARS-CoV2 vaccination few months before, referred to our E.R. with complain of dyspnoea and chest pain. COVID-19 molecular test resulted positive and CT Scan of the chest confirmed the presence of several areas of ground-glass opacity and consolidation together with bilateral pleural effusion (right 6 cm with pulmonary atelectasis; left 2 cm), not requiring drainage. Moreover, it showed severe calcification of both the aortic valve and root. Transthoracic echocardiogram showed eccentric LV hypertrophy with diffuse hypokinesia (EF 20–25%), ectatic ascending aorta (45 mm) with severe LF-LG aortic stenosis (AVAi 0.19 cm2) and moderate regurgitation, moderate-severe mitral regurgitation. During hospitalization in the COVID-19 Unit, despite O2 therapy she experienced worsening of the respiratory status with concomitant pulmonary oedema, hypotension and acute kidney injury, requiring administration of i.v. dobutamine and high dose diuretics. After gradual stabilization and COVID-19 negativization on 10th molecular test, she was transferred to our Coronary Care Unit. Coronary angiography showed absence of significant stenoses in the main vessels. In the following days the patient underwent a new clinical deterioration with dyspnoea, hypotension (BP 85/50 mmHg), oliguria and ankle swelling, requiring Ventimask O2 therapy and Dobutamine infusion. Transtoracic echocardiogram confirmed EF of 25% with PASP 30 mmHg. We decided to perform a ‘Rescue’ TAVI procedure, facilitated by extra-corporeal cardiac and respiratory support. CT Angiography of the chest, performed with low-dose contrast injection under amines infusion, showed severly calcific aortic valve with large sizes of the ring (Virtual Basal Ring area 620 mm2, perimeter 91 mm), measures compatible with the largest sizes of TAVI prostheses. After Veno-Arterial Extracorporeal Membrane Oxygenation (ECMO) cannulation, we performed the implantation of a 34 mm Evolut R (Medtronic) TAVI prosthesis, post-dilated with 24 mm balloon for under-expansion due to massive calcification. During both self-expandable TAVI delivery and balloon inflation the patient underwent two phases of cardiac arrest, during which the ECMO flow provided a proper circulatory support. Conclusions Since percutaneous valve replacement the patient’s recovery was fast with rapid ECMO removal and discontinuation of inotropic therapy. Few weeks after discharge, at first follow-up examination, the patient appeared asymptomatic, in excellent clinical conditions. 701 Figure

Transcatheter valve replacement: a revolution

Degenerative aortic stenosis is the most common valvular disease worldwide; however, its physiopathology remains poorly understood. Although, developments in prevention of this disease have remained relatively stagnant, the last decade has brought about innovative treatment options incorporating different percutaneous and surgical approaches. These advances have allowed physicians to offer relief to high-risk patients, previously deemed nonsurgical. Increasingly, there is a shift toward offering percutaneous valve replacement to moderate and low-risk patients with aortic stenosis. Enthusiasm for a new treatment option must always be tempered by caution; as defining appropriate patient selection is essential to achieve optimal outcomes.

Nursing protocol in transcatheter aortic valve implantation: care guideline

Objective: To validate a nursing care protocol by specialist nurses, contributing to the care delivered to patients undergoing percutaneous valve replacement. Methods: This cross-sectional, prospective, quantitative study adopted the Content Validity Index (CVI) to verify level of agreement regarding this protocol's total set of items. Results: The CVI obtained for each item of the protocol, verified using a validation instrument, was greater than the minimum required that is 0.80, on average. Conclusion: The development of a protocol intended to guide care provided to patients who have undergone TAVI, improves patient safety and minimizes health problems, so that the implementation of specific strategies for the development of actions performed by nurses is essential.

Transcatheter Pulmonary Valve Replacement in a Carcinoid Heart

Carcinoid heart disease presents as right-sided heart failure attributable to the dysfunction of the tricuspid and pulmonary valves. Although surgical valve replacement is the mainstay of treatment when patients become symptomatic, it is associated with substantial perioperative mortality rates. We present a case of severe pulmonary valve stenosis secondary to carcinoid heart disease, treated successfully with percutaneous valve replacement. A 67-year-old man with severe pulmonary valve stenosis was referred to our center for pulmonary valve replacement. The patient had a history of metastatic neuroendocrine tumor of the small bowel with carcinoid syndrome, carcinoid heart disease, and tricuspid valve regurgitation previously treated with surgical valve replacement. Because of the patient's severe chronic obstructive pulmonary disease and hostile chest anatomy seen on a computed tomographic scan dating from previous cardiothoracic surgery, we considered off-label percutaneous valve replacement a viable alternative to open-heart surgery. A 29-mm Edwards Sapien XT valve was successfully deployed over the native pulmonary valve. There were no adverse sequelae after the procedure, and the patient was discharged from the hospital the next day. This case report shows that percutaneous valve replacement can be a valid option in carcinoid heart disease patients who are not amenable to surgical valve replacement.

Ventricular perforation as a complication of percutaneous valve replacement

Aortic stenosis (AS) is the most commonly encountered valvular disease in developed countries. Once symptomatic, this disease carries a dismal prognosis. Patients unfit for surgical valve replacement may require transcatheter aortic valve implantations (TAVI). We present a complication of this novel approach where a prosthetic valve is delivered through the femoral artery by means of a Retroflex delivery system developed by Edwards Lifesciences.

FLOW PATTERNS AND HEMODYNAMIC EFFICACY ANALYSIS IN A NOVEL PERCUTANEOUS STENTED AORTIC VALVE

Recently, percutaneous valve replacement has emerged as an alternative treatment for stenosis of mitral, aortic, and pulmonary valves, replacing the surgical approach and providing a new perspective on transcatheter placement of cardiac valves. The conventional open heart surgery does not suit most of the cardiothoracic patient population for various reasons. Percutaneous valve replacement has started becoming the first choice for surgical replacement of the cardiac valves. Under such a scenario where good potent porcine valves made from the pericardium of pigs are being made available, the real question is designing and developing cost effective stents to bear these valves. The ones that are imported are highly expensive which cannot be afforded by some of the Indian population. This also has substantial benefits from the standpoints of health, safety, and cost. The manufacturing of a stented aortic valve is an absolutely critical job, which requires proper designs, finite element analysis, and flow dynamics studies. This paper forms the base for an eventual manufacture of stented aortic valves, giving in-depth details pertaining to design and implantation of the bioprosthesis in the aorta with flow pattern analysis postimplantation and its hemodynamic efficacy analysis. Blood flow analysis and associated hemodynamic analysis help to understand the leakage resistance of the stented valve. A valve of this kind will enable minimal invasive cardiac surgeons to perform percutaneous aortic valve replacement with ease. This would also be an economic procedure allaying the high costs that are typically involved in conventional open heart surgery. We believe that this model has great potential for helping to set up a protocol for the growing of a tissue engineered heart valve construct.