Transcatheter aortic valve implantation (TAVI)

Introduction:

Transcatheter aortic valve implantation (TAVI) has revolutionized the management of aortic stenosis, offering a less invasive option for patients deemed high-risk or inoperable for traditional surgical aortic valve replacement. However, performing TAVI in complex cases presents unique challenges that require advanced skills and expertise. This case study presents a challenging TAVI procedure performed by Dr. Amit Gupta at a national conference, highlighting the intricacies and nuances involved in managing complex anatomical and clinical scenarios.

Pre-procedural Assessment:

Pre-procedural evaluation revealed severe calcific aortic stenosis with a valve area of 0.7 cm² and a mean pressure gradient of 45 mmHg. Additionally, coronary angiography demonstrated significant coronary artery disease with patent grafts.

Challenges:

Severe calcification: The patient’s aortic valve exhibited extensive calcification, posing a challenge for accurate valve positioning and deployment.
Complex anatomy: Previous coronary artery bypass graft surgery resulted in altered cardiac anatomy, complicating vascular access and device delivery.
Comorbidities: The patient’s concomitant conditions, including chronic kidney disease and coronary artery disease, increased the procedural risk and necessitated careful peri-procedural management.

Procedure:

Under conscious sedation and local anesthesia, percutaneous femoral access was obtained. Pre-dilatation of the aortic valve was performed using a high-pressure balloon to facilitate valve delivery. Transesophageal echocardiography (TEE) and fluoroscopy were used for real-time imaging guidance throughout the procedure. Despite the challenges posed by severe calcification and complex anatomy, the transcatheter valve was successfully positioned and deployed using a self-expanding bioprosthesis.

Post-procedural Course:

Immediate post-procedural TEE confirmed proper valve positioning and adequate function with mild paravalvular leak. The patient was transferred to the cardiac intensive care unit for close monitoring and management of hemodynamic parameters. He experienced an uneventful recovery with resolution of symptoms and was discharged home on post-procedural day 3.

Follow-up:

At 1-month follow-up, the patient reported significant improvement in symptoms with no evidence of valve dysfunction or complications. Serial echocardiographic evaluations demonstrated stable valve function and resolution of paravalvular leak.