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Percutaneous Closure of an Incompetent Aortic Valve Using an Occluder Device in a Patient with Left Ventricular Assist Device

Feider, Andrew MD; Dhawan, Richa MD; Chaney, Mark MD

doi: 10.1213/ANE.0b013e3182a4e433
Cardiovascular Anesthesiology: Echo Rounds
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Supplemental Digital Content is available in the text.Published ahead of print September 3, 2013

From the Department of Anesthesia and Critical Care, University of Chicago Medical Center, Chicago, Illinois.

Accepted for publication January 29, 2013.

Published ahead of print September 3, 2013

Funding: No funding.

Consent Statement: The author states that the report describes the care of 1 patient. This patient consented to publication of the report.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site.

Reprints will not be available from the authors.

Address correspondence to Andrew Feider, MD, Department of Anesthesia and Critical Care, University of Chicago Medical Center, 5841 S. Maryland Ave., Room E408, Chicago, IL 60637. Address e-mail to feideraj@gmail.com.

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CASE PRESENTATION

A 56-year-old man with a history of ischemic cardiomyopathy status post–HeartMate II® axial-flow left ventricular assist device (LVAD) placement was admitted to our institution with symptoms of cardiogenic shock. His workup revealed new-onset severe aortic insufficiency (AI) (Video 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A589). Because of severe coagulopathy from hepatic failure, the patient was considered a poor candidate for surgical aortic valve (AV) closure. Instead, a novel procedure was devised using a percutaneous septal occluder device to anatomically close the AV. The patient consented to publication of this report.

The patient underwent general anesthesia and endotracheal intubation. Intraoperatively before the procedure, a focused transesophageal echocardiography (TEE) examination revealed the following: (1) A continuous eccentric jet of severe AI; (2) An aortic annulus diameter of 24 mm; (3) A sinus of Valsalva diameter of 31 mm; (4) Patent left and right coronary ostia; (5) Moderately reduced right ventricular function; and (6) Severely dilated left ventricle with severely reduced function.

After gaining femoral arterial access, a guidewire was advanced under fluoroscopy. Then using TEE, the delivery catheter containing a 25-mm diameter Amplatzer® cribriform septal occluder (St. Jude Medical Corp., St. Paul, MN) was visualized passing through the AV. Before deployment, LVAD flow was temporarily decreased to 1 L/min to reduce the trans-AV gradient and prevent shifting or embolization of the device. Next, the distal disk of the device was deployed within the left ventricular outflow tract (LVOT) (Fig. 1). Last, the proximal disk was deployed within the sinus of Valsalva and delivery catheter removed.

Figure 1

Figure 1

After the procedure, repeat TEE examination revealed: (1) Proper device position, with the narrow waist of the double disk resting within the AV (Fig. 2/Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A590); (2) No residual AI identified via color flow Doppler (Fig. 3/Video 3, see Supplemental Digital Content 3, http://links.lww.com/AA/A591); (3) Normal mitral function; 4) Patent left coronary ostium but poorly visualized right coronary ostium because of acoustic shadowing from the device; (5) Unchanged right ventricular function; and (6) Reduced left ventricular dilation with unchanged function.

Figure 2

Figure 2

Figure 3

Figure 3

After successful completion of the procedure, the patient was tracheally extubated and transported to the intensive care unit. He had complete resolution of his symptoms and was discharged home 5 days later. The patient continues to do well 6 months postprocedure.

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DISCUSSION

In patients with LVADs, new-onset moderate or severe AI is a known complication with an occurrence rate as high as 51% at 18 months postoperatively.1 Furthermore, patients who develop postoperative AI have only an 82% 2-year survival rate as compared with 93% for those without AI.2 Significant AI will divert LVAD output back into the ventricle, thereby reducing forward flow and end-organ perfusion. If AI is identified at the time of LVAD insertion, it is not uncommon to surgically close the AV. In this patient, LVAD forward flow was restored by anatomically closing the AV with a percutaneous occluder device. The obvious drawbacks of AV closure include the inability of the left ventricle to produce forward blood flow in the setting of LVAD failure.

A thorough TEE evaluation is vital to the success of this procedure. First, using a midesophageal long-axis view of the AV during midsystole, digital calipers should be placed at the hinge points of the AV leaflets (inner edge to inner edge) to measure aortic annulus diameter.3 The sinus of Valsalva diameter should also be measured in this view. It is important to obtain multiple measurements to ensure accuracy. The Amplatzer® cribriform septal occluder comprises 2 expandable disks of equal diameter, separated by a narrow waist (Fig. 2). It is available in sizes with disk diameters of 25, 30, and 35 mm. Optimal device size should be one slightly larger than the measured aortic annulus diameter. If this is achieved, the fully expanded disks will be too large to migrate across the AV, thus anchoring the occluder device in place. Because aortic pressure is higher than left ventricular pressure, anchoring of the proximal disk within the sinus of Valsalva is most critical. However, it is also important to use a device with a diameter smaller than that of the sinus of Valsalva. This helps to maximize blood flow to the coronary ostia.

After guidewire insertion, TEE can be used to ensure the advancing delivery catheter does not divert from the aorta into the LVAD outflow cannula. The long-axis view of the ascending aorta at the level of the right pulmonary artery yields a view of the outflow cannula anastomosis.4 Next, images of the midesophageal AV long-axis and AV short-axis views are used to ensure the delivery catheter passes through the AV. The catheter tip must reside in the LVOT when the distal disk is deployed. If advanced too far, it may disrupt the mitral valve subvalvular apparatus. Once deployed (Fig. 1), the distal disk must be withdrawn until abuttingthe ventricular side of the AV. This will ensure the proximal disk deploys within the sinus of Valsalva, not the LVOT.

After deployment of the second occluder disk, the native AV should reside within the narrow waist of the device. However, the AV leaflets themselves may be difficult to visualize using TEE (Video 2, see Supplemental Digital Content 2, http://links.lww.com/AA/A590). Color flow Doppler in the AV long-axis view may show turbulence between the disks but no residual AI (Fig. 3/Video 3, see Supplemental Digital Content 3, http://links.lww.com/AA/A591). The presence of mitral stenosis caused by the distal disk should also be excluded. Because the device could impede blood flow to the coronary arteries, their patency is confirmed before and after the procedure by obtaining an AV short-axis view with color Doppler and slightly withdrawing the TEE probe to reveal the coronary ostia. If the right ostium cannot be visualized because of acoustic shadowing, it is important to confirm right ventricular function remains unchanged and no new wall motion abnormalities are present. In addition, coronary angiography may be necessary.

In conclusion, it is well described that TEE is useful during placement of cardiac occluder devices for both conventional and off-label uses.5,6 In this novel procedure, TEE was indispensable in determining the size, guiding the positioning, and confirming the correct placement of the occluder device.

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Clinician’s Key Teaching Points

By Nikolaos J. Skubas, MD, and Roman M. Sniecinski, MD

  • In a patient supported by a left ventricular (LV) assist device (LVAD), blood is pumped from the LV to the ascending aorta. Proper LV unloading and recovery of LV function is impossible if blood flows retrograde via an incompetent aortic valve (AV). New-onset, moderate, or severe aortic insufficiency (AI) develops in more than half of the LVAD patients and is associated with decreased survival.
  • In an LVAD-supported patient, the AV (imaged with 2 dimensional and color Doppler) should remain closed throughout the cardiac cycle with no more than trivial aortic regurgitation. The nonpulsatile nature of the LVAD flow will worsen any AI, because the AV is exposed to systemic pressure continuously. The AI jet will be imaged throughout the cardiac cycle in the LV outflow tract.
  • In this case, an LVAD patient developed cardiogenic shock from severe AI, and an occluder device was inserted percutaneously via the femoral artery and positioned across the incompetent AV. Transesophageal echocardiography (TEE) measurements of the diameters of the LV outflow tract and sinus of Valsalva enabled the selection of the appropriate occluder size. The 2 disks were positioned under TEE guidance so that the mitral valve function and coronary flow were not compromised.
  • The proper position of an occluder device is facilitated by intraoperative TEE, so that guidewires and catheters are inserted safely, the discs are deployed properly, and the cessation of the abnormal flow is verified.
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DISCLOSURES

Name: Andrew Feider, MD.

Contribution: This author helped write the manuscript.

Attestation: Andrew Feider approved the final manuscript.

Name: Richa Dhawan, MD.

Contribution: This author helped write the manuscript.

Attestation: Richa Dhawan approved the final manuscript.

Name: Mark Chaney, MD.

Contribution: This author helped write the manuscript.

Attestation: Mark Chaney approved the final manuscript.

This manuscript was handled by: Martin J. London, MD.

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REFERENCES

1. Cowger J, Pagani FD, Haft JW, Romano MA, Aaronson KD, Kolias TJ. The development of aortic insufficiency in left ventricular assist device-supported patients. Circ Heart Fail. 2010;3:668–74
2. Toda K, Fujita T, Domae K, Shimahara Y, Kobayashi J, Nakatani T. Late aortic insufficiency related to poor prognosis during left ventricular assist device support. Ann Thorac Surg. 2011;92:929–34
3. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJChamber Quantification Writing Group; American Society of Echocardiography’s Guidelines and Standards Committee; European Association of Echocardiography. . Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardio logy. J Am Soc Echocardiogr. 2005;18:1440–63
4. Chumnanvej S, Wood MJ, MacGillivray TE, Melo MF. Perioperative echocardiographic examination for ventricular assist device implantation. Anesth Analg. 2007;105:583–601
5. Phillips SA, Thompson A, Abu-Halimah A, Crenshaw MH, Zhao DX, Pretorius M. Percutaneous closure of aortic prosthetic paravalvular regurgitation with two amplatzer septal occluders. Anesth Analg. 2009;108:437–8
6. Rigatelli G, Dell’Avvocata F, Ronco F, Giordan M, Cardaioli P. Patent oval foramen transcatheter closure: results of a strategy based on tailoring the device to the specific patient’s anatomy. Cardiol Young. 2010;20:144–9

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