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Table of Contents
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 4  |  Page : 203-206

Importance of imaging for transcatheter aortic valve replacement in dextrocardia with situs inversus totalis


1 Department of Cardiovascular Surgery, Santa Maria Hospital-GVM Care and Research, Bari, Italy
2 Department of Anesthesia and Intensive Care Unit, Giovanni XXIII-Policlinico, Bari, Italy

Date of Web Publication31-Dec-2018

Correspondence Address:
Dr. Dambruoso Pierpaolo
Department of Cardiovascular Surgery, Santa Maria Hospital-GVM Care and Research, Via De Ferrariis 22; 70124 Bari
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_25_18

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  Abstract 


We describe imaging utility for trans-femoral aortic valve replacement (TAVR) with 29-mm Core-Valve Evolut R self-expanding valve prosthesis in a singular case of an old man with symptomatic severe aortic stenosis (SAS), dextrocardia, and situs inversus totalis. Cardiac computed tomography plays a pivotal role from pre-procedural planning to TAVR by our heart-team. It gives crucial information to choice the appropriate valve sizing, to avoid paravalvular leak, coronaries obstructions, or serious aortic injuries. To the best of our knowledge, this is the first case of TAVR successfully performed in Italy in a patient with symptomatic SAS, dextrocardia and situs inversus totalis.

Keywords: Cardiac computed tomography, dextrocardia, severe aortic stenosis, situs inversus totalis, transcatheter aortic valve replacement


How to cite this article:
Pierpaolo D, Pasquale R, Giorgio MP, Gaetano C. Importance of imaging for transcatheter aortic valve replacement in dextrocardia with situs inversus totalis. Res Cardiovasc Med 2018;7:203-6

How to cite this URL:
Pierpaolo D, Pasquale R, Giorgio MP, Gaetano C. Importance of imaging for transcatheter aortic valve replacement in dextrocardia with situs inversus totalis. Res Cardiovasc Med [serial online] 2018 [cited 2019 Jan 17];7:203-6. Available from: http://www.rcvmonline.com/text.asp?2018/7/4/203/249049




  Introduction Top


Surgical aortic valve replacement (SAVR) is the classical therapy for symptomatic severe aortic stenosis (SAS); however, the risks associated with surgery, even if minimally invasive, may be prohibitive in elderly, frail, high-risk patients with serious comorbidities, preferring percutaneous more conservative approach based on encouraging data on long-term durability.[1]

Both the American College of Cardiology/STS and European Society of Cardiology/European Association of Cardiothoracic Surgery believe that three dimensional reconstruction of aortic valve/root and aortic-iliac vasculature with multi-slice cardiac computed tomography (CT) plays a fundamental role for transfemoral aortic valve replacement (TAVR).[2],[3]

We show the importance of imaging in the management of TAVR with 29-mm Core-Valve Evolut R self-expanding aortic valve prosthesis (Medtronic, Irvine, California, United States) in a singular case of an old man with SAS, dextrocardia and situs inversus totalis.

To the best of our knowledge, this is the first case of TAVR in a patient with dextrocardia and situs inversus totalis performed in Italy. Seven cases (five transfemoral and two trans-apical) were carried out previously somewhere else.[4],[5],[6],[7],[8],[9],[10]


  Case Report Top


An 80-year-old male was admitted to Santa Maria Hospital-Bari, in our cardiovascular department, for symptomatic SAS, dextrocardia, and situs inversus totalis. After obtaining signed informed consent from the patient, we performed echocardiography that revealed restricted aortic surface area (0.55 cm2) with mean gradient of 65 mmHg associated with secondary severe pulmonary hypertension (systolic pulmonary artery pressure of 65 mmHg); left ventricle systolic function was moderately reduced (ejection fraction of 45%).

At the admission, the patient was symptomatic at rest, with increased dyspnea on mild exertion, systemic hypertension, chronic atrial fibrillation, peripheral vascular disease with right leg's amputation, pacemaker's substitution after infection, anxious-depressive syndrome, and chronic obstructive pulmonary disease. The patient, extremely frail, was previously considered not eligible for SAVR or minimally invasive aortic surgery by our heart team, for serious clinical status (American Society of Anesthesiology/ASA IV) and high preoperative surgical risk (Euroscore II, 8.67%).

Cardiac CT confirmed the radiographic diagnosis of dextrocardia showing an inverted orientation of the left ventricle apex as well as the great vessels [Figure 1].
Figure 1: Cardiac computed tomography showing dextrocardia with situs inversus totalis

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The day before the procedure our heart-team performed an extensive diagnostic workup based mainly on CT study and measurements [Figure 2].
Figure 2: Patient's aortic valve-root complex geometry reconstruction with all derived measurements

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On the morning of the procedure, to facilitate TAVR, intravenous sedation and analgesia with midazolam, fentanyl, plus local anesthesia in the groin area with xylocaine were used. Trough right femoral vein a temporary pacemaker was inserted in the right ventricle. The right femoral artery was cannulated to insert a pigtail device in the aorta for fluoroscopic guide. Trough left femoral artery a Proglyde was inserted for pre-occlusion, followed by an introducer (14 Fr) and an Amplatz Superstiff guide to cross the native valve. Osypca ballon (23 mm × 40 mm) was used for aortic valvuloplasty to displace the native leaflets and calcifications for TAVR. Synchronized rapid ventricular pacing was done to allow aortic balloon valvuloplasty followed by implantation of 29-mm CoreValve Evolut R self-expanding aortic valve prosthesis. The fluoroscopic control showed a trivial leak [Figure 3]. Hemostasis was completed using AngioSeal (8 Fr) for the right femoral access, ProGlide, and AngioSeal (8 Fr) for the left one.
Figure 3: (a) Aortography showing dextrocardia (b) balloon aortic valvuloplasty (c) Initial positioning of 29-mm core valve self-expanding aortic valve (d) deployment of the valve (e) final appearance (f) angiographic controls

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At the end of the procedure, the patient was stable, the echo showed normal prosthetic valve function with mean gradient across the aortic valve of 6 mmHg, without pericardial effusion. The following course of events was not meaningful, and consequently, the patient was discharged from hospital on day 3 postoperative without complications.


  Discussion Top


CT scan reconstruction imaging of aortic valve-root and derived measurements are extremely useful to face up to several technical challenges when performing TAVR in a patient with SAS, dextrocardia and situs inversus totalis.

Our CT scan pre-procedural measurements are displayed in [Figure 2]:

  1. Measurements of the left ventricular outflow tract (maximum diameter, perimeter-derived mean diameter, and surface area), of aortic valve annulus (maximum diameter, perimeter-derived mean diameter, and surface area), of sinuses of Valsalva (D1-D2-D3, maximum diameter, perimeter-derived mean diameter and surface area) to choose the correct valve sizing to avoid paravalvular leak or fatal aortic injuries
  2. Measurements of the right, left coronary, and sino-tubular junction height to choose the optimal position of valve deployment to avoid coronaries obstructions
  3. Measurements of sino-tubular junction (maximum diameter, perimeter-derived mean diameter, and surface area) and ascending aorta (maximum diameter, perimeter, and surface area) to avoid fatal aortic injuries during TAVR.


CT reconstruction gives also important measurements to define the suitable fluoroscopic projection angle to align the three Valsalva sinuses to facilitate TAVR.

This complex and extensive diagnostic pre-procedural work-up played a fundamental role to perform successfully TAVR with 29-mm CoreValve Evolut R self-expanding aortic valve prosthesis.

This case report confirms the utility of augmented reality technology to optimize a complex cardiac procedure in a patient with altered fluoroscopic orientation.


  Conclusions Top


This report suggests that accurate peri-procedural imaging study is extremely important to facilitate TAVR with 29-mm CoreValve Evolut R self-expanding aortic valve prosthesis without complication in a rare case of a patient with symptomatic SAS, dextrocardia, and situs inversus totalis. Multidisciplinary and extensive workup by heart team is useful to make as easy as possible several technical challenges encountered when performing TAVR in a patient with altered fluoroscopic orientation due to dextrocardia and situs inversus totalis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mack MJ, Leon MB, Smith CR, Miller DC, Moses JW, Tuzcu EM, et al. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): A randomised controlled trial. Lancet 2015;385:2477-84.  Back to cited text no. 1
    
2.
Holmes DR Jr., Mack MJ. Trans-catheter valve therapy: A professional society overview from the American College of Cardiology Foundation and the Society of Thoracic Surgeons. J Am Coll Cardiol 2011;58:445-55.  Back to cited text no. 2
    
3.
Vahanian A, Alfieri O, Al-Attar N, Antunes M, Bax J, Cormier B, et al. Transcatheter valve implantation for patients with aortic stenosis: A position statement from the European Association of Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC), in Collaboration with the European Association of Percutaneous Cardiovascular Interve ntions (EAPCI). Eur Heart J 2008;29:1463-70.  Back to cited text no. 3
    
4.
Dubois CL, Herijgers P. Trans-catheter aortic valve implantation in situ s inversus totalis. Interact Cardiovasc Thorac Surg 2012;15:542-3.  Back to cited text no. 4
    
5.
vH Weich H, van WyK J, van Zyl W, Vivier R, Philips A, Mabin T. First case of transapical implantation of an aortic valve in a patient with dextrocardia. J Cardiothorac Surg 2012;7:24.  Back to cited text no. 5
    
6.
Romaguera R, Roura G, Gómez-Hospital JA, Gómez-Lara J, Moris C, Cequier A, et al. CoreValve® aortic bioprosthesis implantation in a patient with situs inversus totalis with dextrocardia. Rev Esp Cardiol (Engl Ed) 2013;66:409-10.  Back to cited text no. 6
    
7.
Good RI, Morgan KP, Brydie A, Beydoun HK. Nadeem SN. Transfemoral aortic valve implantation for Severe Aortic Stenosis in a Patient with Dextrocardia Situs Inversus. Can J Cardiol 2014;30:1108.  Back to cited text no. 7
    
8.
Agrawal Y, Miller M, Pratt JW, Martin D, Kalavakunta JK, Saltiel F, et al. Transcatheter aortic valve replacement for severe aortic stenosis in dextrocardia with situs inversus:First reported case in the United States. Int J Cardiol 2016;209:137-8.  Back to cited text no. 8
    
9.
Alrifai A, Kabach M, Lovitz L, Rothenberg M, Nores M, Fanari Z, et al. Severe aortic stenosis in dextrocardia with situs invertus and anomalous single coronary ostium treated with transcatheter aortic valve replacement. Cardiovasc Revasc Med 2018;19:33-6.  Back to cited text no. 9
    
10.
Pattakos G, Chrissoheris M, Halapas A, Papadopoulos K, Kourkoveli P, Bouboulis N, et al. Transcatheter aortic valve replacement in a patient with dextrocardia and situs inversus totalis. Ann Thorac Surg 2018. pii: S0003-4975(18)30839-7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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