Mihailovič Peter Marko, Žižek David, Vitez Luka, Holc Primoz, Klokočovnik Tomislav, Bunc Matjaž
Department of Cardiology, University Medical Center Ljubljana, Slovenia.
Department of Cardiovascular Surgery, University Medical Center Ljubljana, Slovenia.
Front Cardiovasc Med. 2023 Aug 10;10:1206811. doi: 10.3389/fcvm.2023.1206811. eCollection 2023.
Aortic regurgitation is a major concern following transcatheter aortic valve implantation (TAVI), as even low-grade regurgitation is associated with increased mortality. This is of particular concern to patients with pre-existing aortic disease who are at increased risk of TAVI valve slippage. Furthermore, conduction system disturbances after TAVI, namely left bundle branch block (LBBB), may have an additional detrimental effect on cardiac function.
This report documents a successful treatment strategy in a frail patient with a bicuspid aortic valve and aortic disease after valve-sparing surgical repair in 1998, who subsequently developed aortic stenosis and underwent TAVI with an Evolut R self-expanding aortic valve. The progression of aortic disease, aortic root dilatation, and leaflet degeneration over the following years caused aortic regurgitation of the self-expanding aortic valve, resulting in left ventricular dilatation and heart failure along with LBBB and left ventricular (LV) mechanical dyssynchrony. Diagnostic workup of the patient showed persistence of the aneurysm distal to the graft with a dissection spanning the ascending aorta, arch, and terminating proximal to the aortic isthmus. After consideration by the cardiac team, a balloon-expandable valve was chosen for a valve-in-valve (ViV) procedure to provide sufficient radial force to expand the existing valve and correct the regurgitation. Due to the anatomy, a J-wire and pigtail catheter were successfully used for a safe approach and placement of the valve. Following the procedure, intermittent complete atrioventricular block was observed in addition to the pre-existing left bundle branch block, necessitating resynchronization pacing. Due to anatomical considerations, ease of placement, and the expected good level of resynchronization due to the proximal block, we opted for left bundle branch pacing, which showed improvement in left ventricular dyssynchrony and LV function at follow-up.
Valve-in-valve implantation of a balloon-expandable Myval TAVI device to treat aortic regurgitation caused by slippage and right leaflet disfunction of slef valve is feasible in challenging anatomical scenarios. Left bundle branch pacing is a viable alternative to correct mechanical dyssynchrony in complex patients with LBBB and anatomical challenges necessitating resynchronization.
经导管主动脉瓣植入术（TAVI）后主动脉瓣反流是一个主要问题，因为即使是轻度反流也与死亡率增加相关。这对于已有主动脉疾病且TAVI瓣膜移位风险增加的患者尤为重要。此外，TAVI后的传导系统紊乱，即左束支传导阻滞（LBBB），可能会对心脏功能产生额外的不利影响。
本报告记录了一名体弱患者的成功治疗策略，该患者1998年接受保留瓣膜的手术修复治疗二叶式主动脉瓣和主动脉疾病，随后发展为主动脉狭窄并接受了使用Evolut R自膨胀主动脉瓣的TAVI。在接下来的几年里，主动脉疾病的进展、主动脉根部扩张和瓣叶退变导致自膨胀主动脉瓣出现主动脉瓣反流，导致左心室扩张和心力衰竭，同时伴有LBBB和左心室（LV）机械不同步。对该患者的诊断检查显示，移植物远端的动脉瘤持续存在，夹层跨越升主动脉、主动脉弓，并在主动脉峡部近端终止。心脏团队经过考虑后，选择了球囊可扩张瓣膜进行瓣中瓣（ViV）手术，以提供足够的径向力来扩张现有瓣膜并纠正反流。由于解剖结构的原因，成功使用J形导丝和猪尾导管实现了安全的瓣膜置入方法。手术后，除了原有的左束支传导阻滞外，还观察到间歇性完全房室传导阻滞，需要进行再同步起搏。由于解剖学考虑、置入的便利性以及近端阻滞预期的良好再同步水平，我们选择了左束支起搏，随访结果显示左心室不同步和左心室功能得到改善。
在具有挑战性的解剖情况下，使用球囊可扩张Myval TAVI装置进行瓣中瓣植入以治疗自体瓣膜移位和右瓣叶功能障碍引起的主动脉瓣反流是可行的。对于患有LBBB且解剖结构复杂需要再同步的患者，左束支起搏是纠正机械不同步的可行替代方法。
