CASE
An 83-year old male had symptomatic severe PAR New York Heart
Association Functional Classification IV with a type III endoleak was
recognized 4 years after TEVAR. A multislice spiral computed tomographic
(MDCT) scan revealed a slightly dilation aortic root and ascending aorta
without any calcification of the aortic valvular cusps. MDCT-scan showed
an annulus perimeter of 86.6 mm and effective diameter of 27.6 mm. The
examination also revealed excessive type III endoleak due to
disconnection of proximal stent graft segments in the upper TAA(Figure 1A-C). The STS risk score revealed an excessive
perioperative mortality risk of 19.1%. The complex anatomy, lack of
calcification landmarks and the block of stainless steel stent-graft at
the intraoperative fluoroscopy angiogram were the challenges during the
TAVR procedure.
The patient was qualified for endovascular treatment of type III
endoleak due to high risk of aneurysmal sac rupture. After initial
angiography to determine the location of the endoleak. The low profile
Valiant Thoracic Stent Graft was delivered with a tight guidewire. The
inserted segment successfully sealed the rupture thoracic graft(Figure 2A-C and Movie S1). Transoesophageal echocardiogram
(TEE) and angiography were used for evaluation of the valve movement and
function (Figure 2 D and Figure 3A-C) . An incision of 3 cm in
the corresponding costal space and then the apical puncture was done and
a super-stiff guidewire was placed in position. A 29 mm J-Valve was
directly inserted into the annulus with the aid of the specifically
designed delivery system. The delivery system was bluntly inserted into
the left ventricle through the apex and advanced into a supra-annular
position under fluoroscopic guidance. While the stainless stent-graft
effect on visual of operation, the three claspers were completely
deployed and were pulled down to make sure the claspers being inside the
aortic sinus. The implantation process was consisted of two steps, in
the first step, the clasper was positioned into the aortic sinuses
correctly. In the second step, the valve was lowed back gently into the
annular plan with the guidance of the claspers embracing the native
leaflets and deployed. A repeat aortic root angiography revealed no
aortic insufficiency (AI) and no paravalvular leak (PVL).(Figure 2 E/E'-H/H' and Movie S2) . TEE was also used to
confirm the valve function during the procedure and showed normal
function of the J-Valve with a mean transaortic pressure gradient
(PGmean) of 4 mm Hg and no aortic insufficiency or PVL (Figure
3D-F ). TTE discharge showed an aortic valve area of 2.6
cm2 with PGmean of 3 mm Hg and 4 mm Hg at 6 months, no
AI. And there were no endoleaks detected during monitoring MDCT scan at
6 months follow-up (Figure 1D-F).