81-year-old female patient with high grade aortic stenosis and increased operative risk.
The patient suffers from aortic valve stenosis, pulmonary hypertension and respiratory dysfunction. In addition she had arterial hypertension, chronic atrial fibrillation and diabetes mellitus.
Under general anesthesia, a right femoral arterial sheath and a right femoral venous guidewire were inserted. A pigtail catheter was then advanced through the femoral sheath to the aortic root. Left anterolateral mimi-thoracotomy was performed opening the pericardium at the apex of the left ventricle. An epicardial pacemaker lead was then introduced, secured by apical purse-string sutures. syngo DynaCT Cardiac images were acquired under rapid biventricular pacing; 3:1 contrast dilution was injected into the aortic root. Guided by the calculations of the 3D volume, the C-arm was placed in an orthogonal position and the segmented image was overlain onto the fluoroscopic image. An antegrade approach was used to negotiate a soft guidewire across the stenotic aortic valve. A 14 F sheath was then advanced into the ascending aorta. A super-stiff guidewire was also advanced into the descending aorta. During a brief episode of rapid ventricular pacing, a 20 mm balloon was inflated to dilate the high grade aortic stenosis. The balloon catheter was exchanged for a 26 mm sheath, which was advanced to position the aortic valve bioprothesis. Positioning was confirmed by angiography and syngo DynaCT Cardiac. An Edwards SAPIEN aortic valve bioprothesis was successfully deployed during a second episode of rapid pacing. Intraoperative transesophageal echocardiography and angiography revealed no relevant aortic insufficiency. The successful transcatheter valve replacement procedure was performed without open-heart surgery.
Thomas Walther, M.D., Ph.D (Department of Heart Surgery, University Leipzig, Heart Center, Leipzig, Germany)
AXIOM Innovations (November 2009, www.siemens.com/healthcare-magazine