A 75-years-old Caucasian male was admitted to our clinic with a mixed aortic valve pathology. He had a positive cardiovascular anamnesis, since he underwent aortic valve replacement with a 27 mm size aortic homograft twenty-two years earlier.
Since then he, performed yearly echocardiographic follow-ups. The first signs of homograft degeneration presented 12 years after the implant with moderate aortic regurgitation and fibro-sclerosis of the aortic wall.
Ten years later there was evidence of worsening of aortic regurgitation in association with moderate stenosis (trans-valvular mean gradient 36 mmHg and maximum velocity of 3,3 m/s).
After 8 months from the last instrumental evaluation the patient went to the emergency department because of new onset dyspnea and fever. A new trans-thoracic echocardiogram showed worsening of the left ventricular ejection fraction (EF 42%), new evidence of left ventricle dilation with an end-diastolic volume (EDV) of 245 ml and vegetation on the aortic leaflets. Blood cultures were positive for C. hominis, which lead to the diagnosis of endocarditis and specific antibiotic therapy was started with Meropenem and Ceftriaxone. After three weeks of therapy, the inflammatory markers were negative, the clinical aspects of the patient were ameliorated and the echocardiogram showed improvement of the EF (52%) and positive remodeling of the left ventricle (EDV 161 ml) while vegetations and severe aortic regurgitation were confirmed, and echocardiographic aortic stenosis parameters worsened (trans-valvular mean gradient 58 mmHg and maximum velocity 5 m/s). Echocardiographic and CT scan images did not show any image suggestive of abscess.
Because of the frailty of the patient, the complexity of a redo-surgery in the setting of an extremely calcified and dilated homograft the heart team proposed an implantation of a transcatheter aortic valve on cardiopulmonary bypass (CPB) through median sternotomy.
Femoro-femoral CPB was established and median re-sternotomy performed. The technique was as follow:
A small aortotomy was performed 2 cm above the calcified and dilated homograft and then the leaflets were explored. The leaflets appeared retracted and heavily calcified (Fig. 1), and permitted only the passage of an Hegar sized 19 mm. Small pieces of the homograft were collected to be cultured
the degenerated leaflets were removed, after careful evaluation and confirmation of absence of abscesses, and the height of the coronary ostia measured (Fig. 2a); the height of the main left was 9 mm while that of the right coronary ostium was 10 mm and these measurements were compared with the height of the transcatheter prosthesis (Fig. 2b). Then the deployment at nominal volume of a #23 Sapien 3 (Edwards Lifesciences, Irvine, USA) balloon-expandable prosthesis was performed under direct view (Fig. 2c)
at the end we noticed a satisfactory expansion of the prosthesis-in-homograft (Fig. 3) so we did not perform any post-dilatation
finally thromboendoarterectomy of the degenerated homograft was performed to remove the most calcified parts and to allow direct closure with Proline 4–0. The weaning from CPB was quick and easy.
The following in-hospital course was uneventful, the homograft biopsies were negative and the post-operative echocardiogram showed only a mild residual aortic regurgitation (partially para-valvular). The patient was discharged in the 7th post-operative day.
After 14 months from the procedure the patient is alive and well, asymptomatic, and the residual mild aortic regurgitation is stable.
