Overtchouk Pavel, Delhaye Cédric, Sudre Arnaud, Modine Thomas
Department of Cardiology and Cardiovascular Surgery, Centre Hospitalier Regional et Universitaire de Lille (CHRU de Lille), 2 Avenue Oscar Lambret, Lille, France.
Eur Heart J Case Rep. 2018 May 4;2(2):yty049. doi: 10.1093/ehjcr/yty049. eCollection 2018 Jun.
Transcatheter aortic valve implantation (TAVI) can be challenging in case of complex anatomy such as bicuspid aortic valve stenosis or situs inversus. This report illustrates a successful procedure in a patient with both conditions after careful pre-operative planning and per-operative guidance by means of a novel software.
We report the case of a 71-year-old man that presented a type 0 bicuspid aortic valve stenosis and situs inversus. We performed transfemoral TAVI using the Edwards Sapien 3 transcatheter heart valve (THV) and a novel software that provides insight for patient anatomy through computed tomography (CT) extracted three-dimensional reconstruction before the procedure aiming at improving THV positioning during the procedure through fusion of a CT-extracted virtual aortic annulus on the fluoroscopy screen and enhancing of calcifications that can be considered as anatomical landmarks. The Edwards Sapien 3 THV was accurately implanted in a supra-annular fashion. Post-operative echocardiography showed an excellent result without any para-prosthetic leak, and the patient reported symptom improvement.
During TAVI the angiographic appearance of the cusps of a bicuspid aortic valve is irregular and asymmetric, which can lead to malpositioning, paravalvular regurgitation, and increased rates of pacemaker implantation after TAVI. Furthermore, usual anatomical landmarks can be even more disturbed by the situs inversus totalis. We believe that pre-operative three-dimensional reconstruction and per-operative fluoroscopy image processing, provided by software such as the one presented in this case report, can provide precious guidance for TAVI in patients with complex and unusual anatomy.
在诸如二叶式主动脉瓣狭窄或脏器反位等复杂解剖结构的情况下，经导管主动脉瓣植入术（TAVI）可能具有挑战性。本报告展示了在经过仔细的术前规划以及借助一种新型软件进行术中引导后，为一名同时患有这两种病症的患者成功实施手术的过程。
我们报告了一名71岁男性患者的病例，该患者患有0型二叶式主动脉瓣狭窄和脏器反位。我们使用爱德华 Sapien 3经导管心脏瓣膜（THV）并借助一种新型软件进行经股动脉TAVI，该软件在术前通过计算机断层扫描（CT）提取的三维重建为患者解剖结构提供深入见解，旨在通过在荧光透视屏幕上融合CT提取的虚拟主动脉瓣环以及增强可被视为解剖标志的钙化来改善术中THV的定位。爱德华 Sapien 3 THV以瓣环上方式准确植入。术后超声心动图显示结果极佳，无任何人工瓣膜旁漏，且患者报告症状有所改善。
在TAVI期间，二叶式主动脉瓣瓣叶的血管造影表现不规则且不对称，这可能导致位置不当、人工瓣膜旁反流以及TAVI后起搏器植入率增加。此外，全内脏反位会使通常的解剖标志更加紊乱。我们认为，如本病例报告中所展示的软件提供的术前三维重建和术中荧光透视图像处理可为解剖结构复杂和异常的患者进行TAVI提供宝贵的指导。
