Feasibility of transapical aortic valve replacement through a left ventricular apical diverticulum
© Ferrari et al.; licensee BioMed Central Ltd. 2013
Received: 12 July 2012
Accepted: 17 December 2012
Published: 7 January 2013
Transapical aortic valve replacement is an established technique performed in high-risk patients with symptomatic aortic valve stenosis and vascular disease contraindicating trans-vascular and trans-aortic procedures. The presence of a left ventricular apical diverticulum is a rare event and the treatment depends on dimensions and estimated risk of embolisation, rupture, or onset of ventricular arrhythmias. The diagnosis is based on standard cardiac imaging and symptoms are very rare. In this case report we illustrate our experience with a 81 years old female patient suffering from symptomatic aortic valve stenosis, respiratory disease, chronic renal failure and severe peripheral vascular disease (logistic euroscore: 42%), who successfully underwent a transapical 23 mm balloon-expandable stent-valve implantation through an apical diverticulum of the left ventricle. Intra-luminal thrombi were absent and during the same procedure were able to treat the valve disease and to successfully exclude the apical diverticulum without complications and through a mini thoracotomy. To the best of our knowledge, this is the first time that a transapical procedure is successfully performed through an apical diverticulum.
KeywordsAortic valve replacement Transcatheter aortic valve implantation Left ventricular apical diverticulum
Transcatheter aortic valve replacement (TAVR) is an established minimally invasive technique for patients with severe symptomatic aortic valve stenosis and surgical high-risk profile. Predominant accesses are the transapical and the transfemoral ones, but, recently, also the trans-subclavian and the trans-aortic access have been employed to perform successful transcatheter aortic valve procedures. However, severe atherosclerosis, heavy calcifications, small diameters and tortuosities limit the trans-vascular and the trans-aortic access, whereas a left ventricular dysfunction, presence of apical thrombi and anatomical left ventricular anomalies (such as an aneurysm or an apical diverticulum) can constrain the transapical approach . Recently, we already demonstrated that TAVR can be safely performed through a chronic left ventricular apical aneurysm, as long as apical thrombi are absent . In this new report, and for the first time ever, we show the proof that a transapical aortic valve procedure can be safely performed through a left ventricular apical diverticulum without apical thrombi, and that the apical diverticulum can be excluded during the same procedure.
A left ventricular diverticulum is defined as an outpunching structure that contains endocardium, myocardium and pericardium and displays normal contraction. They are distinguished from the aneurysms which do not contract, have a fibrous wall and exhibit paradoxical motion. Earlier studies report a prevalence of diverticula in 0.4% or 3% of 750 cardiac necropsy cases [3, 4]. They are congenital (in absence of history of injured myocardium), asymptomatic (except for rare cases of ventricular tachycardia), and most of them are placed in the apex . There is no consensus about the treatment of this ventricular anomaly and the management should be tailored to the clinical characteristics of each patient, taking into consideration the onset of potential complications (embolization, rupture, ventricular arrhythmias) . The surgical treatment consists of an excision and placement of a patch.
During a transapical transcatheter aortic valve replacement, the apex is prepared with two purse-string sutures and then punctured in order to introduce the delivery system. Thus, in the presence of a diverticulum without intraluminal thrombi, and in the absence of good alternative vascular and accesses, the transapical approach appears to be adequate in order to treat, simultaneously, both the apical diverticulum and the aortic valve stenosis.
In our experience, we prepared two larger pledgeted purse-string sutures in order to detect good thick myocardium surrounding the diverticulum: using this stratagem, part of the diverticulum was successfully excluded when the sutures were tied and we did not experienced apical bleeding.
With regards to the postoperative management, we did not change our protocols but we performed a computed tomography scan to visualize the resulting apical anatomy. In conclusion, TAVR procedures can be safety and efficacy performed through a left ventricular apical diverticulum, in the absence of intraluminal thrombi.
The patient gave his informed consent for publication.
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