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Endo-Bentall Procedure Using Off-the-Shelf Catheter Devices to Repair an Aorto-Atrial Fistula

2023; Lippincott Williams & Wilkins; Volume: 16; Issue: 4 Linguagem: Inglês

10.1161/circinterventions.122.012848

1941-7632

Bradley G. Leshnower, Yazan Duwayri, William J. Nicholson, Hiroki Ueyama, Patrick Gleason, Nikoloz Shekiladze, Adam B. Greenbaum, Vasilis Babaliaros,

Aortic aneurysm repair treatments

HomeCirculation: Cardiovascular InterventionsVol. 16, No. 4Endo-Bentall Procedure Using Off-the-Shelf Catheter Devices to Repair an Aorto-Atrial Fistula Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBEndo-Bentall Procedure Using Off-the-Shelf Catheter Devices to Repair an Aorto-Atrial Fistula Bradley G. Leshnower, Yazan M. Duwayri, William J. Nicholson, Hiroki Ueyama, Patrick T. Gleason, Nikoloz Shekiladze, Adam B. Greenbaum and Vasilis Babaliaros Bradley G. LeshnowerBradley G. Leshnower Correspondence to: Bradley G. Leshnower, MD, Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365 Clifton Rd, Suite A 2213, Atlanta, GA 30322. Email E-mail Address: [email protected] https://orcid.org/0000-0002-2290-1729 Division of Cardiothoracic Surgery (B.G.L.), Emory University School of Medicine, Atlanta, GA. , Yazan M. DuwayriYazan M. Duwayri https://orcid.org/0000-0002-0847-4118 Division of Vascular and Endovascular Therapy (Y.M.D.), Emory University School of Medicine, Atlanta, GA. , William J. NicholsonWilliam J. Nicholson Section of Interventional Cardiology, Division of Cardiovascular Medicine (W.J.N.), Emory University School of Medicine, Atlanta, GA. , Hiroki UeyamaHiroki Ueyama Division of Cardiovascular Medicine Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.U., P.T.G., N.S., A.B.G., V.B.). , Patrick T. GleasonPatrick T. Gleason https://orcid.org/0000-0001-5739-9030 Division of Cardiovascular Medicine Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.U., P.T.G., N.S., A.B.G., V.B.). , Nikoloz ShekiladzeNikoloz Shekiladze Division of Cardiovascular Medicine Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.U., P.T.G., N.S., A.B.G., V.B.). , Adam B. GreenbaumAdam B. Greenbaum https://orcid.org/0000-0001-7496-5954 Division of Cardiovascular Medicine Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.U., P.T.G., N.S., A.B.G., V.B.). and Vasilis BabaliarosVasilis Babaliaros https://orcid.org/0000-0002-9438-0846 Division of Cardiovascular Medicine Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, GA (H.U., P.T.G., N.S., A.B.G., V.B.). Originally published3 Apr 2023https://doi.org/10.1161/CIRCINTERVENTIONS.122.012848Circulation: Cardiovascular Interventions. 2023;16Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: April 3, 2023: Ahead of Print A 71-year-old man presented with acute congestive heart failure, cardiogenic shock, and acute renal failure requiring dialysis. His medical history included atrial fibrillation, chronic kidney disease, diabetes, metastatic prostate cancer, and surgical aortic valve replacement with a 29-mm bioprosthetic valve for severe aortic insufficiency 4 years before presentation. Computed tomography and echocardiography demonstrated a well-seated aortic valve, with a fistula from the noncoronary sinus of Valsalva to the left atrium (Figure 1; Video S1). This fistula was likely due to healed endocarditis and produced severe volume overload and cardiogenic shock. A multidisciplinary heart team convened and given his Society of Thoracic Surgeons predicted risk of mortality of 15.98% determined that he was at prohibitive risk for redo sternotomy, aortic root replacement. Therefore, he was offered an endovascular aortic root and ascending aortic repair. The goal of this procedure was to exclude the sinus of Valsalva from aortic blood flow and thereby close the aorto-left atrial fistula. An operative approach consisting of a modular fenestrated endovascular valved conduit with coronary artery stenting to reconstruct the aortic root was selected.Download figureDownload PowerPointFigure 1. Fistula from the noncoronary sinus of Valsalva to the left atrium. 2D indicates 2 dimensional; CF, color flow; and LA, left atrium.Operative TechniqueThe patient was brought to a hybrid operating room, and open exposures of the right axillary artery, left common carotid artery, and left common femoral artery were performed. Coronary angiography demonstrated no obstructive coronary artery disease, and intravascular ultrasound demonstrated a left main diameter of 5.5×8.1 mm with a 15-mm left main coronary trunk and a right coronary artery diameter of 6.9×8.1 mm. Two deflectable sheaths (Oscor Palm Harbor, FL) were placed into the right axillary artery, a 16F expandable sheath (Edwards, Irvine, CA) was placed into the right femoral artery, and cardiopulmonary bypass was initiated via the left femoral artery and right femoral vein. A 42×94-mm Zenith Alpha thoracic stent-graft (Cook Medical, Bloomington, IN) was modified at the bedside using an ophthalmic electrocautery pen to create 2 fenestrations for the coronary arteries, as well as placement of multiple constraining sutures. After clamping the left common carotid artery, a perfusion catheter connected to the cardiopulmonary bypass circuit was placed distal to the clamp to provide cerebral perfusion, and the fenestrated endograft was introduced into the proximal left carotid artery. The endograft was advanced across the aortic valve (Figure 2A; Video S1), rotated in its partially deployed, constrained configuration until the optimal position of the fenestrations for cannulation of the coronary arteries was identified. The endograft was then deployed, while partially constrained, pinning the leaflets of the bioprosthetic aortic valve open. The fenestrations provided antegrade coronary blood flow.Download figureDownload PowerPointFigure 2. Procedural angiogram. A, Deployment of endograft with fenestration. B, Advancing coronary stent-grafts within the fenestration. C, Deployment of Sapien 3. D, Distal balloon expansion of endograft. E, Deployment of stent-grafts within the fenestration. F, Final aortogram after distal ascending aortic endograft sealed with second endograft.Next, the left and right coronary arteries were cannulated using the deflectable sheaths from the right axillary artery via the endograft fenestrations. Balloon-expandable stent-grafts (Viabahn VBX; Gore, Flagstaff, AZ) were positioned into the coronary arteries but not deployed, 6×39 mm into the left and 6×29 mm into the right (Figure 2B). At this point, a 29-mm Sapien 3 transcatheter aortic valve (Edwards) was deployed via the right femoral artery inside the endograft at the level of the bioprosthetic aortic valve (Figure 2C). The distal aortic endograft was balloon expanded (Coda; Cook Medical) to break the constraining sutures (Figure 2D). The coronary stent-grafts were then deployed and the proximal ends flared inside the endograft with a 10-mm balloon (Figure 2E). After completion, coronary angiograms confirmed patency of the coronary stents; the patient was weaned from cardiopulmonary bypass. The distal ascending aortic endograft was sealed with a 45×10-mm Conformable TAG Thoracic Endoprosthesis (Gore) to extend the distal aortic seal zone to the base of the innominate artery (Figure 2F).Approximately 20 minutes after separation from cardiopulmonary bypass, the patient developed hemodynamic instability and the transesophageal echocardiography demonstrated severe right ventricular dysfunction. Cardiopulmonary bypass was reinitiated, angiographic patency of the left coronary artery was confirmed, but the right coronary artery stent was unable to be cannulated. Therefore, the patient was converted to a peripheral veno-arterial extracorporeal membrane oxygenation circuit and underwent cardiac computed tomography, which demonstrated right coronary artery malperfusion caused by detachment of the patent right coronary artery stent-graft from the aortic endograft (Figure 3). This was likely due to extreme angulation of the right coronary artery, which only manifested after the guidewire was removed. A bridging VBX 7×39 mm right coronary stent-graft was implanted between the aortic endograft and the detached coronary stent-graft and the proximal end was flared with a 10-mm balloon inside the endograft. This resolved the right coronary artery malperfusion, and the patient was weaned off veno-arterial extracorporeal membrane oxygenation the next day and extubated neurologically intact on postoperative day 4. After a prolonged course, the patient was discharged to a rehabilitation facility on postoperative day 23. A follow-up computed tomography showed the fenestrated endograft, stents, and Sapien 3 assembly to be intact without thrombus. (Figure 4). The final transthoracic echocardiography revealed no residual fistula (Figure 5; Video S1).Download figureDownload PowerPointFigure 3. Detachment of the right coronary artery stent-graft from the aortic endograft.Download figureDownload PowerPointFigure 4. Final computed tomography. LCA indicates left coronary artery; and RCA, right coronary artery.Download figureDownload PowerPointFigure 5. Final transthoracic echocardiography. 2D indicates 2 dimensional; CF, color flow; LA, left atrium; and LV, left ventricle.DiscussionTo our knowledge, this is the first complete endovascular aortic root repair using commercially available, off-the-shelf devices. Previously reported endo-Bentall procedures utilized transapical access via left thoracotomy to treat ascending aortic pathology with either (1) a custom-fabricated device having a transcatheter valve connected to an aortic endograft with branches designed for the coronary arteries1 or (2) a transcatheter valve placed inside a thoracic aortic endograft with large fenestrations to nonselectively perfuse the coronary arteries.2 The modular transcatheter approach described was feasible because the patient had sufficient ascending aortic length (>10 cm) and an aortic diameter <46 mm to accommodate current commercially available endograft devices.The importance of this case lies in the promise of endovascular therapy for patients with lethal aortic root pathology who are unable to tolerate open aortic root replacement via sternotomy or thoracotomy. Despite initial right coronary stent-graft separation resulting in coronary malperfusion, utilization of veno-arterial extracorporeal membrane oxygenation afforded sufficient hemodynamic stability to perform diagnostic cardiac computed tomography and restore normal perfusion with a bridging second right coronary stent-graft. Our approach is applicable to patients without acceptable options pending commercial availability of purpose-built devices. This report demonstrates the technical steps (Figure 6) and feasibility of a transcarotid minimally invasive endo-Bentall with a strategy that involves transcatheter aortic valve deployment inside a fenestrated endograft with stent-grafting of the coronary arteries using peripheral mechanical circulatory support.Download figureDownload PowerPointFigure 6. Illustration of the modular endovascular aortic root repair.Article InformationSources of FundingNone.Supplemental MaterialVideo S1Disclosures Dr Leshnower is a member of the scientific advisory board for Artivion, Inc, and is a consultant for Endospan, Inc. Dr Duwayri serves as a consultant for Cook Medical. Dr Nicholson has received proctoring and advisory board honoraria from Abbott Vascular, Boston Scientific, Medtronic, and Asahi Intecc. Dr Gleason has received institutional research support from Edwards Lifesciences, Medtronic, and Abbott Vascular. Drs Babaliaros and Greenbaum have received institutional research support from Abbott Vascular, Ancora Heart, Edwards Lifesciences, Gore Medical, Jena Valve, Medtronic, Polares Medical, Transmural Systems, and 4C Medical; have received consulting fees from Abbott Vascular, Edwards Lifesciences, and Medtronic; and have equity interest in Transmural Systems. The other authors report no conflicts.Footnotes*B.G. Leshnower and Y.M. Duwayri contributed equally.For Sources of Funding and Disclosures, see page 201.Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCINTERVENTIONS.122.012848.Correspondence to: Bradley G. Leshnower, MD, Division of Cardiothoracic Surgery, Emory University School of Medicine, 1365 Clifton Rd, Suite A 2213, Atlanta, GA 30322. Email bleshno@emory.eduReferences1. Gaia DF, Bernal O, Castilho E, Ferreira CBND, Dvir D, Simonato M, Palma JH. First-in-human endo-Bentall procedure for simultaneous treatment of the ascending aorta and aortic valve.JACC Case Rep. 2020; 2:480–485. doi: 10.1016/j.jaccas.2019.11.071CrossrefMedlineGoogle Scholar2. Gandet T, Westermann D, Conradi L, Panuccio G, Heidemann F, Rohlffs F, Kolbel T. Modular endo-Bentall procedure using a "Rendez-Vous access".J Endovasc Ther. 2022; 29:711–716. doi: 10.1177/15266028211065959CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Alberts T, Eberl S and Hermanns H (2023) Transesophageal echocardiography during surgery of the thoracic aorta in adults, Vessel Plus, 10.20517/2574-1209.2023.37 Resch T (2023) Endovascular repair of type A dissection - A long and winding road, Journal of Vascular Surgery, 10.1016/j.jvs.2023.07.060, 78:6, (1367-1368), Online publication date: 1-Dec-2023. Ghoreishi M, Chahal D, Shah A, Kang J, Hirsch J, Tran D, McCloskey D, Shkullaku M, Gupta A, Strauss E, Dahi S, Taylor B and Toursavadkohi S (2023) First-in-Human Endovascular Aortic Root Repair (Endo-Bentall) for Acute Type A Dissection, Circulation: Cardiovascular Interventions, 16:10, (e013348), Online publication date: 1-Oct-2023.Ueyama H, Greenbaum A, Leshnower B, Keeling B, Block P, Byku I, Ligon R, Grier E, Shekiladze N, Gleason P, Xie J, Kim D, Babaliaros V and Duwayri Y (2023) Physician-Modified Endograft–Facilitated Transcatheter Pulmonary Valve Replacement in Large Right Ventricular Outflow Tract, Circulation: Cardiovascular Interventions, 16:9, (e013123), Online publication date: 1-Sep-2023. April 2023Vol 16, Issue 4 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/CIRCINTERVENTIONS.122.012848PMID: 37009733 Originally publishedApril 3, 2023 Keywordsaortaendovascular proceduresthoracictranscatheter aortic valve replacementPDF download Advertisement SubjectsCatheter-Based Coronary and Valvular Interventions