Sasi Viktor, Fontos Géza, Kormányos Árpád, Vértesaljai Márton, Ruzsa Zoltán
Division of Invasive Cardiology, Department of Internal Medicine, Medical Faculty, Albert Szent-Györgyi Clinical Center, University of Szeged, Semmelweiss str. 8, 6725 Szeged, Hungary.
Gottsegen National Cardiovascular Center, Budapest, Hungary.
Eur Heart J Case Rep. 2024 Jul 25;8(8):ytae366. doi: 10.1093/ehjcr/ytae366. eCollection 2024 Aug.
Severe aortic paravalvular leaks (PVLs) after surgical mechanical aortic valve replacement (AVR) represent a high risk for congestive heart failure, haemolysis, and infective endocarditis. This is the first reported case of distal radial artery (DRA) access for severe mechanical aortic PVL closure with a sequential double vascular plug guided by computed tomography angiography (CTA), transoesophageal echocardiography (TOE), and 3D TOE in an acute setting.
A 51-year-old male presented with significant mixed aortic valve disease. Aortic valve replacement was performed (Slimline Bicarbon A-25 mm) according to guidelines. Four and 16 days later, a re-exploration was carried out due to pericardial effusion. Four months after discharge from rehabilitation, the patient was readmitted due to worsening dyspnoea on exertion and then at rest. Transthoracic echocardiography, TOE, and consequently, CTA, revealed severe PVL, following which the procedure of transcatheter PVL closure was chosen, with a preference for DRA access. After a CTA scan analysis and angiographic, TOE, and 3D TOE visualization of the leak, a 14/5 mm and a 10/5 mm vascular plug (AVPIII) were deployed to achieve good results. A 9-month clinical, echocardiographic, and CTA follow-up revealed good long-term results.
For transcatheter PVL closure, CTA is helpful for not only vascular access planning, but also a visualization of the magnitude of the leak, location, and device planning. This case report demonstrates that the distal radial approach is feasible in patients with severe mechanical aortic valve PVL retrograde transcatheter closure. DRA access could possibly represent less bleeding and vascular access site complications when compared with femoral access and has some potential advantages over regular radial access.
外科机械主动脉瓣置换术（AVR）后出现严重主动脉瓣瓣周漏（PVL）会导致充血性心力衰竭、溶血和感染性心内膜炎的高风险。这是首例在急性情况下，在计算机断层扫描血管造影（CTA）、经食管超声心动图（TOE）和三维TOE引导下，经桡动脉远端（DRA）入路使用序贯双血管塞封堵严重机械性主动脉瓣PVL的报道病例。
一名51岁男性患有严重的混合性主动脉瓣疾病。按照指南进行了主动脉瓣置换术（Slimline Bicarbon A - 25 mm）。术后4天和16天，因心包积液进行了再次手术探查。康复出院4个月后，患者因运动时呼吸困难加重，进而静息时也出现呼吸困难而再次入院。经胸超声心动图、TOE检查，随后CTA检查显示严重PVL，之后选择经导管PVL封堵术，优先采用DRA入路。在对漏口进行CTA扫描分析、血管造影、TOE及三维TOE可视化后，置入了一个14/5 mm和一个10/5 mm的血管塞（AVPIII），取得了良好效果。9个月的临床、超声心动图和CTA随访显示长期效果良好。
对于经导管PVL封堵术，CTA不仅有助于血管入路规划，还能显示漏口大小、位置及装置规划。本病例报告表明，严重机械性主动脉瓣PVL逆行经导管封堵患者采用桡动脉远端入路是可行的。与股动脉入路相比，DRA入路可能出血更少，血管入路部位并发症更少，且相对于常规桡动脉入路有一些潜在优势。
