Post on 08-Nov-2021
Successful TAVI case using the BAV as bridge to TAVI in severe AS patient with very high risk
Sejong General HospitalCheol Woong Yu, MD, PhD
2010 Sejong Cardiovascular Symposium
Case 1• M/68• CC: DOE Fc III~IV (onset; 1 months ) and
cardiogenic shock, altered mentality.• P.I.; He was undergoing HF therapy due to
severe AS at other hospital but transferred to our hospital because of aggravation of HF and unstable condition.
• P/Hx; HTN, CHF (since 1 year ago), heavy alcoholics
• No prev cardiac surgery, No bypassed vessel
2010 Sejong Cardiovascular Symposium
Lab findings
• V/S BP 80/55, RR 32, • Renal function: Ccr 30ml/min (B/Cr
98/2.55)• AST/ALT 1879/1777, TB 2.7, uric acid;22.8• INR 2.09• Troponin T;0.299, ProBNP;33325, CK-
MB;31.9• ABGA;PH 7.456-PCO2 20.6-PO2 101.6- BE -
6.6• CBC;WBC 19.5 Hg 12.9(MCV74.4, MCH
25.4)-Plt 197K
2010 Sejong Cardiovascular Symposium
Chest X ray
2010 Sejong Cardiovascular Symposium
Transthoracic Echocardiography
2010 Sejong Cardiovascular Symposium
Transthoracic Echocardiography
Moderate to severe LV systolic dysfunctionModerate MR, LVE, LAE,
2010 Sejong Cardiovascular Symposium
Transthoracic Echocardiography
• LV 68/58mm, EF 31%, AVA=0.7cm2 by CE• AV peak/mean PG=93/63mmHg
2010 Sejong Cardiovascular Symposium
Very high risk patient
• Severe AS with severe LV systolic dysfx, mod MR
• CHF with pul edema, • cardiogenic shock• ARF on CKD• Congestive hepatopathy• LC(?)
• Logistic Euroscore; 74% STS; 18%
2010 Sejong Cardiovascular Symposium
The next day…
• The patient was more aggravated..
• -> BP 70/40..and anuria, azotemia, mental change despite of use of all inotropics
What should I do at this situation?
2010 Sejong Cardiovascular Symposium
Can the BAV be troubleshooter for this crucial moment?
Z-med 22x30mm,superstiff Amplatz 035 wire, 4atm
2010 Sejong Cardiovascular Symposium
Can the BAV be troubleshooter for this crucial moment?
2010 Sejong Cardiovascular Symposium
Hemodynamic tracing during BAV
2010 Sejong Cardiovascular Symposium
Post BAV TTE• LV 70/53mm, EF 40% (<-30%), AVA=1.1cm2 (<-0.7)• AV peak/mean PG=99/63mmHg•(<- 93/63mmHg)• Mod to severe AR
2010 Sejong Cardiovascular Symposium
PostBAV course…
• V/S stable, 80~60/40~55 -> 120/70• Mental alert• CRRT apply-> azotemia improved• LFT improved
3 days later, sudden cardiac arrest developed and the patient died !!
2010 Sejong Cardiovascular Symposium
Case 2• M/77• CC: DOE Fc III~IV (onset; 2 months )• P.I.; He was undergoing TACE therapy due to
HCC at other hospital and developed CHF during that therapy. So, he was transferred to our hospital because of aggravation of HF after diagnosis of severe AS
• P/Hx; HTN, DM, recent stroke, HCC (7 times TACE) , radiation pneumonitis(?)
• NO prev cardiac surgery, No bypassed vessel
2010 Sejong Cardiovascular Symposium
Lab findings
• V/S BP 131/63, RR 42 • Renal function: normal• LFT;normal• PFT; mild obstructive lung disease• ABGA;PH 7.457-PCO2 38.5-PO2 61.6- BE 4.0• CBC;WBC 4860 Hg 11.1(MCV 98.0, MCH
33.2)-Plt 189K
2010 Sejong Cardiovascular Symposium
Chest X ray and EKG
A.Fib with complete AV block
2010 Sejong Cardiovascular Symposium
TTEAVA=0.74/0.6 by CE/Planimetry, Peak/Mean PG=129/71 mmHgPeak V;5.7m/s, EF=79%, mild to mod AR, MR, TR, PA pr;58mmHg
2010 Sejong Cardiovascular Symposium
What is the next step ?..
Permanent pacemaker implantation
After PM implantation , the patient continuely complained of dyspnea and orthopnea…
BAV..?
2010 Sejong Cardiovascular Symposium
BAV…
TYSHAK 23x30mm, Amplatzer superstiff 035x26020% contrast, 2 atm x3
2010 Sejong Cardiovascular Symposium
Hemodynamic tracing between pre and post BAV
Mean PG: 83 -> 51mmHg
2010 Sejong Cardiovascular Symposium
Post BAV TTEAVA=0.95cm2 (<-0.74), Peak/Mean PG=101/59 mmHg(<-129/71)Peak V;5m/s, EF=79%, mild AR , MR, TR, PA pr;73mmHg
2010 Sejong Cardiovascular Symposium
Post BAV clinical course..
Pleural effusion remained but symptomatically stable
2010 Sejong Cardiovascular Symposium
2 weeks after BAV, TAVI was safely performed
AP Caudal 11.2 Ascendra balloon 26mm
2010 Sejong Cardiovascular Symposium
2 weeks after BAV, TAVI was safely performed
Edwards SAPIEN THV 26mm TEE finding; optimal implantation
2010 Sejong Cardiovascular Symposium
Post TAVI TEE
2010 Sejong Cardiovascular Symposium
Post TAVI TTEAV peak/mean PG=17.5/9.5mmHg
2010 Sejong Cardiovascular Symposium
Post TAVI clinical course
No further pleural effusion V/S stableNo orthopnea, N dyspneaImproved functional capacity
Take home message
•BAV can play an important role, such as bridge to TAVI, especially in very high risk patient.
•To achieve optimal BAV result as a bridge role and to avoid complication associated with BAV procedure, further studies is needed , such as about optimal balloon size, inflation pressure, postBAV pr gradient, and so on.