WSHIMA - Case24: TAVR
Preoperative Diagnosis: Severe Aortic Stenosis
Postoperative Diagnosis: Severe Aortic Stenosis
PROCEDURE(S) PERFORMED: Replacement of Aortic Valve with bioprosthetic valve.
Transcatheter aortic valve replacement, 29 mm S3 Valve.Transapical approach
SURGEONS:
INDICATIONS: The patient was diagnosed with severe aortic stenosis. The patient is also being treated for atrial fibrillation and type II diabetes.
TRANSCATHETER AORTIC VALVE REPLACEMENT:
Detailed informed consent was obtained. General anesthesia was induced and the patient was prepped and draped in the usual sterile fashion. Femoral and radial access was obtained by seldinger technique and a transvenous pacing lead was floated into the RA. The right femoral arterial sheath was then upsized over a dilator to 18F delivery sheath. A pigtail catheter was placed into the right coronary cusp. A second arterial cather was introduced into the aortic root and the aortic valve was crossed. A pigtail cather was then advanced into the LV and exchanged for a stiff wire. We then attempted to advance the valve into the aorta but were unable to pass it through the iliac vessel. We were forced to abandon the femoral approach. I then made a 5 cm incision in the left fifth intercostal space and performed a left anterior thoracotomy exposing the apex of the heart. I opened the pericardium and placed pericardial sutures. Then placed four pledgeted sutures into the apex of the heart. A needle was placed into the apex and a 6 fr. sheath advanced over a wire. this was then upsized to the 18 fr sheath for delivery of the valve.. The 29 mm valve was then advanced across the aortic valve and deployed. TEE verified minimal paravalvular leak and a completion angiogram confirmed the absence of aortic injury. The apex was then closed with the pledgeted sutures. The thoracotomy was closed with a pericostal suture and the skin and subcutaneous tissues were closed in three layers. Perclose devices were used to closed the right femoral access site with excellent hemostasis. The patient tolerated the procedure well and was transferred to the intensive care unit in good condition. There were no identified complications, and a chest tube was left in the left pleural space. All instrument counts were correct.