Page 100 - Journal of Structural Heart Disease Volume 5, Issue 4

Meeting Abstracts
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132. HYBRID TRANSCATHETER AORTIC VALVE REPLACEMENT IN A 3-YEAR OLD WITH COMPLEX CONGENITAL HEART DISEASE
Juan Samayoa1,2, Adil Husain1,2, Dongngan Truong1,2, Mary Hunt Martin1,2, Robert Gray1,2
1University of Utah, Salt Lake City, USA. 2Primary Childrens Hospital, Salt Lake City, USA
Background: Transcatheter aortic valve replacement (TAVR), has revolutionized the treatment of aortic stenosis (AS), offering a less invasive alternative to surgery. The use of TAVR is rapidly extending to lower-risk patients expected to have longer survival, yet minimal data exist regarding its use in pediatric patients with congenital heart disease (CHD). TAVR is uniquely attractive for CHD patients, as most have increased surgical risks and are likely to require mul- tiple future operations. This case report describes success- ful TAVR via a hybrid, trans-aortic approach in the setting of a young child with complex CHD requiring aortic valve replacement.
Case Presentation: A 3-year-old male with double outlet right ventricle, d-malposed great arteries, bicuspid pul- monary valve with valvar and sub-valvar pulmonary ste- nosis, and a large ventricular septal defect (VSD) initially underwent modified Blalock-Taussig shunt as a neonate, followed by an arterial switch operation, VSD closure and tricuspid valvotomy at 7 months old. Secondary to pro- gressive mitral regurgitation (MR) and neo-AS, he under- went a third open-heart surgery with mitral and neo-aortic valvotomy at 10 months of age. He developed progressive neo-AS and underwent a balloon valvuloplasty at 2 years of age. In the year following balloon valvuloplasty, he devel- oped severe neo-aortic insufficiency (AI), moderate neo-AS (mean gradient 33mmHg), and moderate-severe MR. Given his underlying complex CHD and three prior open-heart operations, he was deemed high risk for surgical aortic valve replacement, therefore a TAVR approach was consid- ered. A CT scan demonstrated favorable anatomy for TAVR, with a neo-aortic valve annular area of 299mm2, suitable for a 20mm SAPIEN 3 valve. Given his small size and inad- equate vascular access, a hybrid approach was planned. In the cardiac catheterization lab, following median sternot- omy, a suitable access site was located on the transverse aortic arch just proximal to the origin of the innominate artery allowing for sufficient distance between the access site and valve landing zone. A 20mm SAPIEN 3 valve was advanced to the neo-aortic annulus and deployed during rapid RV pacing. Post deployment angiography demon- strated appropriate valve position, no significant valvar or para-valvar AI, and normal flow through bilateral coronary arteries. His chest was closed in the catheterization lab and
the patient was extubated several hours later. He was dis- charged home 5 days after the procedure. At 6-month fol- low-up, he remains asymptomatic, with increased energy levels. Echocardiography shows trace AI, mild AS (mean gradient 15mmHg), and mild MR.
Conclusion: To our knowledge, this is the first report of TAVR performed in a young child with complex biven- tricular CHD. An alternative access approach via hybrid trans-aortic access to the aorta allows for TAVR in smaller patients with inadequate peripheral access. TAVR may be a reasonable alternative to surgical valve replacement in select pediatric patients, however long-term follow up remains paramount.
133. PROGRESSIVE AORTIC ROOT DILATATION MAY INDUCE FRUSTRATION OF THE FORAMEN OVALE; A CASE REPORT OF ANKYLOSING SPONDYLITIS PRE- SENTED WITH CRYPTOGENIC STROKE
Sahar Elshedoudy, Eman Eldokla, Reem Rashed
Tanta university, Tanta, Egypt
Introduction: PFO is a remnant of the fetal circulation, right to left shunt across it can be associated with differ- ent pathological conditions . PFO pathogenicity is possibly exacerbated by the dilated aortic root by increasing atrial septal mobility and potentiation of PFO shunting.(1-4)
Case Presentation: A 33 year old female complaining of chronic back pain, was diagnosed as ankylosing spondy- litis. Her first transthoracic echocardiograpy (TTE) 7 years ago, revealed mild aortic root dilation. She missed the fol- low up, then presented 2 months ago with cryptogenic stroke. TTE revealed dilated aortic root = 45 mm, with aneurysmal bouncing of inter-atrial septum. TEE revealed an inter-atrial septal aneurysm, PFO with right to left shunt by color Doppler confirmed by massive right to left shunt during contrast echocardiography . Associated Very prom- inent redundant whip like Eustachian valve. TCD confirm the TEE finding and revealed grade IV right to left shunt across the middle cerebral artery denoting huge intracra- diac shunt.
The decision was to close PFO percutaneously
The procedure was done under general anesthesia, with TEE and fluoroscopic guidance. An Occlutech PFO occluder (23/25) was chosen , a 9 Fr long sheath was placed,from the femoral venous approach through the PFO in the left atrium , the implantation technique of PFO have already been described () . From the start the Eustachian valve was captured by a steerable ablation catheter introduced
Journal of Structural Heart Disease, August 2019
Volume 5, Issue 4:75-205