Transfemoral aortic valve replacement as a solution in aortic valve stenosis and coronary artery fistulas
2019; Elsevier BV; Volume: 159; Issue: 1 Linguagem: Inglês
10.1016/j.jtcvs.2019.04.025
ISSN1097-685X
AutoresGiulio Folino, Valentina Bernardinello, Massimiliano Carrozzini, Jonida Bejko, Gino Gerosa, Tomaso Bottio,
Tópico(s)Infective Endocarditis Diagnosis and Management
ResumoCentral MessageAnatomic and hemodynamic implications of coronary artery fistulas concomitant with acquired valvular disease are paramount for the optimal interventional strategy, surgical versus percutaneous.See Commentary on page e31. Anatomic and hemodynamic implications of coronary artery fistulas concomitant with acquired valvular disease are paramount for the optimal interventional strategy, surgical versus percutaneous. See Commentary on page e31. A 66-year-old man in New York Heart Association functional class III as a result of severe aortic stenosis was referred to our institution (Video 1). The patient had symptoms of fatigue and orthopnea. His electrocardiogram showed sinus rhythm, with signs of left ventricular hypertrophy. Echocardiography showed preserved left ventricular ejection fraction, no alteration of the regional contractility, severe aortic stenosis. A preoperative coronary angiography, performed as part of the routine preoperative examination, showed nonsignificant coronary artery stenosis but did reveal the presence of multiple systemic arterial connections to coronary arteries and to the pulmonary trunk vasculature. The finding was further investigated with multidetector computed tomographic angiography of the thoracic vessels, which revealed complex abnormal vascular structures connecting the left descending, circumflex and right coronary arteries, the pulmonary trunk, and systemic arteries (left internal thoracic artery, bronchial arteries, and an anomalous vessel originating from the descending aorta; Figure 1). Multidetector computed tomographic angiography better clarified the anatomy, the 3-dimensional geometry, and the connections of the fistulas than did standard coronary angiography (Figure 2).Figure 1Anomalous vessel originating from the descending aorta. After aortic crossclamping, the perfusion pressure was not satisfactory as a result of the systemic-to-coronary arterial shunt, established mainly throughout this anomalous vessel.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2Volume-rendered reconstruction of the 3-dimensional anatomy of the anomalous vascular connection (systemic to coronary artery). Multidetector computed tomographic angiography and volume-rendered reconstruction correctly characterize complex fistulas.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Considering the patient's clinical characteristics, age younger than 75 years, Society of Thoracic Surgeons predicted risk of mortality and euroSCORE II less than 4%, no severe comorbidity, no frailty, no previous cardiac surgery, no porcelain aorta, and no previous coronary artery bypass grafting operation or sequelae of chest radiation or chest deformation, the patient was referred for traditional surgery. The surgery was carried out through a median sternotomy. Cardiopulmonary bypass was established through the ascending aorta and the right atrium. All visible fistulas between the aorta and the pulmonary trunk were closed. After aortic crossclamping and partial transversal aortotomy, an attempt to administer antegrade selective hematic cardioplegia into the coronary ostia was made; however, 2 major problems occurred: (1) massive blood backflow from both coronary ostia and (2) low systemic blood pressure after the aortic clamp as a result of the systemic-to-coronary fistulas. Despite blood backflow, cardiac arrest was obtained; however, soon after the end of cardioplegia administration, the heart restored a fibrillating rhythm. Moreover, the amount of backflow was sufficiently massive to make surgical aortic valve replacement challenging. The feeling was that the cardioplegia was washed out by the blood coming from the systemic to coronary arteries shunt. We therefore decided to close the aortotomy and refer the patient for transfemoral aortic valve replacement. Transfemoral aortic valve replacement was performed with no complications. The coronary angiography performed during the transcatheter aortic valve implantation procedure showed the surgical closure of all visible fistulas between the aorta and the pulmonary trunk. Postoperative transthoracic echocardiography showed good prosthesis function, no relevant transvalvular gradient, and minimal periprosthetic leak. The intensive care unit stay was 1 day, and hospital discharge occurred on day 3. Two-month follow-up transthoracic echocardiography confirmed good prosthesis function, with minimal periprosthetic leakage, and the patient was in New York Heart Association functional class I. The patient gave written consent to present his data. A coronary arterial fistula is a connection between one or more of the coronary arteries and a cardiac chamber or great vessel. It is present in the 0.002% of the general population1Zenooz N.A. Habibi R. Mammen L. Finn J.P. Gilkeson R.C. Coronary artery fistulas: CT findings.Radiographics. 2009; 29: 781-789Crossref PubMed Scopus (115) Google Scholar and represents 14% of all the anomalies of coronary arteries.2Buccheri D. Chirco P.R. Geraci S. Caramanno G. Cortese B. Coronary artery fistulae: anatomy, diagnosis and management strategies.Heart Lung Circ. 2018; 27: 940-951Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar Most fistulas have a congenital origin, although they may occasionally be acquired after trauma, percutaneous coronary intervention, and cardiac surgery.3Reidy J.F. Anjos R.T. Qureshi S.A. Baker E.J. Tynan M.J. Transcatheter embolization in the treatment of coronary artery fistulas.J Am Coll Cardiol. 1991; 18: 187-192Crossref PubMed Scopus (231) Google Scholar, 4Somers J.M. Verney G.I. Coronary cameral fistulae following heart transplantation.Clin Radiol. 1991; 44: 419-421Abstract Full Text PDF PubMed Scopus (24) Google Scholar, 5Fuller S. Ravishankar C. Acquired and congenital coronary artery diseases.Pediatr Crit Care Med. 2016; 17: S356-S361Crossref PubMed Scopus (3) Google Scholar Several classifications have been proposed on the basis of either the feeding artery of the fistula or the opening chamber; the first classification comes from Ogden and colleagues,6Ogden J.A. Surgical correction of congenital coronary defects. II. Coronary artery-cardiac chamber fistulas.Conn Med. 1971; 35: 168-172PubMed Google Scholar and a more recent is from Dodge-Khatami and associates.7Dodge-Khatami A. Mavroudis C. Backer C.L. Congenital Heart Surgery Nomenclature and Database Project: anomalies of the coronary arteries.Ann Thorac Surg. 2000; 69: S270-S297Abstract Full Text Full Text PDF PubMed Google Scholar Reviewing the current literature, very few reports of connection between systemic and coronary arteries are present.8Lin C. Han S.C. Fang C.C. Wang S.P. Complex AV fistulas involving three coronary arteries, aorta, left internal mammary artery, vertebral artery and left pulmonary artery—demonstration by MDCT.Int J Cardiol. 2011; 150: e55-e56Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 9Ohkura K. Yamashita K. Terada H. Washiyama N. Akuzawa S. Congenital systemic and coronary-to-pulmonary artery fistulas.Ann Thorac Cardiovasc Surg. 2010; 16: 203-206PubMed Google Scholar In our patient, the complex fistulas simultaneously connected systemic arteries, coronary arteries, and the pulmonary trunk. This is a rare case that is worthy of being reported to plan the best interventional strategy taking into consideration the hemodynamic consequences of a connection between the systemic circulation and the coronary arteries. As emerged from this case, complex coronary fistulas may jeopardize the myocardial protection and influence the systemic perfusion pressure during cardiopulmonary bypass. In complex coronary fistulas, key points to evaluate are as follow: the anatomy of the vascular connections, the presence of systemic vessels feeding the fistulas, and the caliber and the origin of any collector vessel. If these features suggest a great systemic to coronary connection, we suggest considering as first approach for AVR, a procedure that does not requires cardiopulmonary bypass and cardiac arrest. A logical solution is therefore a transcatheter valve replacement, either transapical or transaortic. Other strategies, such as hypothermic cardiopulmonary bypass, ventricular fibrillation, and rapid-deployment bioprosthesis can be considered. Hypothermia imposes longer cardiopulmonary bypass time, however, and it is related to an increased risk of postoperative bleeding,10Tönz M. Mihaljevic T. von Segesser L.K. Schmid E.R. Joller-Jemelka H.I. Pei P. et al.Normothermia versus hypothermia during cardiopulmonary bypass: a randomized, controlled trial.Ann Thorac Surg. 1995; 59: 137-143Abstract Full Text PDF PubMed Scopus (102) Google Scholar systemic inflammatory response, and organ dysfunction. Ventricular fibrillation is suboptimal for myocardial protection because the perfusion of the subendocardium is impaired, particularly in ventricular hypertrophy. This experience teaches (1) that multidetector computed tomographic angiography provides better understanding of the anatomy and 3-dimensional geometry of a complex fistula; (2) that complex coronary fistulas may impair myocardial protection; (3) that we suggest in the presence of coronary fistulas to examine the anatomy of the connections deeply, to check whether systemic vessels are involved, and to consider the caliber and the origin of the collector vessel; (4) that the traditional surgical approach is inutile in the presence of an important systemic-to-coronary arterial shunt; and (5) that percutaneous intervention should be considered as first option in cases similar to the one that we report here. https://www.jtcvs.org/cms/asset/e3438ea2-9854-427e-ad8a-3dd2e13436a1/mmc1.mp4Loading ... Download .mp4 (79.14 MB) Help with .mp4 files Video 1First operating surgeon, Professor T. Bottio, explains the relevance of the case report by means of preoperative and postoperative imaging. Video available at: https://www.jtcvs.org/article/S0022-5223(19)30920-1/fulltext. Commentary: Can coronary artery fistulae be an indication for transarterial aortic valve replacement over surgical aortic valve replacement?The Journal of Thoracic and Cardiovascular SurgeryVol. 159Issue 1PreviewThe experience with a rare single case such as that reported by Folino and colleagues,1 where an attempt at open surgical aortic valve replacement failed because of severe coronary artery fistulae with inability to achieve sustained cardioplegic arrest and good visualization of the aortic valve region, might not ordinarily be considered adequate grounds for future decision making. However, their success with transarterial aortic valve replacement (TAVR) and their description of the difficult and dangerous conditions during their attempt at surgical aortic valve replacement should easily justify resorting to TAVR should a similar case present itself to other surgeons. Full-Text PDF Open Archive
Referência(s)