Accepted Manuscript Transfemoral Aortic Valve Implantation for Severe Aortic Stenosis in a Patient with Dextrocardia Situs Inversus Richard I.S. Good, BA, MBBS, MRCP(UK) Kenneth P. Morgan, BSc, MBChB, MD, MRCP(UK) Alan Brydie, BSc, MBChB, MRCP(UK), FRCR, FRCPC Hussein K. Beydoun, MD, FRCPC, FACC S. Najaf Nadeem, MBBS, FCPS, FACC, FSCAI PII:

S0828-282X(13)01746-7

DOI:

10.1016/j.cjca.2013.12.011

Reference:

CJCA 1070

To appear in:

Canadian Journal of Cardiology

Received Date: 12 June 2013 Revised Date:

25 November 2013

Accepted Date: 17 December 2013

Please cite this article as: Good RIS, Morgan KP, Brydie A, Beydoun HK, Nadeem SN, Transfemoral Aortic Valve Implantation for Severe Aortic Stenosis in a Patient with Dextrocardia Situs Inversus, Canadian Journal of Cardiology (2014), doi: 10.1016/j.cjca.2013.12.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Title: Transfemoral Aortic Valve Implantation for Severe Aortic Stenosis in a Patient

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with Dextrocardia Situs Inversus

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Short title: Transfemoral aortic valve replacement in dextrocardia

Authors:

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Richard I.S. Good, BA, MBBS, MRCP(UK); Kenneth P. Morgan BSc, MBChB, MD, MRCP(UK), Alan Brydie BSc, MBChB, MRCP(UK), FRCR, FRCPC; Hussein K. Beydoun MD, FRCPC, FACC; S. Najaf Nadeem, MBBS, FCPS, FACC, FSCAI

Dr Najaf Nadeem

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Corresponding author:

Assistant Professor, Department of Medicine, Dalhousie University

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Staff Interventional Cardiologist, QE II Health Sciences Center Halifax Infirmary Site

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Room # 6896, 1796 Summer Street Halifax, NS, B3H 3A7 Canada

e-mail: [email protected] Tel: 1-902-473-5769 Fax: 1-902-473 6293 Word count: 1095

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ACCEPTED MANUSCRIPT Good Brief summary:

We report a case of successful percutaneous aortic valve replacement in a

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patient with detrocardia situs inversus and previous coronary artery bypass grafting from the femoral route using the Edwards SAPIEN XT Novaflex+

Transfemoral SystemTM. We highlight that inversion of the Novaflex+ delivery

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system facilitates articulation around a right-sided aortic arch.

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ACCEPTED MANUSCRIPT Good Abstract

Transcatheter aortic valve implantation (TAVR) has grown rapidly over the

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last 10 years. Device and delivery catheter systems have evolved to facilitate the procedure and reduce the risk of associated complications including those

related to vascular access. It is important to understand the utility of the TAVR

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equipment in patients with more challenging anatomy in order to select the most appropriate technique for this complex procedure. We report the first

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case of a patient with detrocardia situs inversus and previous CABG undergoing TAVR from the femoral route using the Edwards SAPIEN XT

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Novaflex+ Transfemoral SystemTM.

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ACCEPTED MANUSCRIPT Good Introduction As experience of transcatheter aortic valve implantation (TAVR) increases (1), operators are being challenged by unusual anatomy. We report the first case

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of TAVR from the femoral route using the Edwards SAPIEN XT Novaflex+ Transfemoral SystemTM in a patient with detrocardia, a right sided aortic arch

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and situs inversus.

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Case Report

A 63 year old gentleman with known dextrocardia situs inversus was admitted to our centre with a history of crescendo angina and shortness of breath. He had undergone coronary artery bypass surgery (CABG) in 2000 receiving a right internal mammary (RIMA) graft to his left anterior descending (LAD) and

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first diagonal (D1) arteries with a further free radial conduit from his RIMA to the first obtuse marginal (OM1) vessel and right coronary artery posterior descending (RPDA) branch. His medical history also included hypertension,

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non-insulin dependent diabetes, remote smoking and chronic obstructive

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pulmonary disease (FEV1 of 1.46l/s).

Physical

examination

revealed

a

body

mass

index

(BMI)

of

38.

Echocardiography demonstrated a severely calcified and restricted, aortic valve with a peak gradient of 93mmHg. Left ventricular (LV) systolic function was preserved. Coronary angiography revealed severe native three vessel disease. There was a well functioning RIMA graft to LAD and D1 and patent radial conduit to OM1. The radial conduit from OM1 to RPDA was occluded

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ACCEPTED MANUSCRIPT Good but there had been no interval change in coronary anatomy since 2007. Simultaneous LV to ascending aorta mean gradient was 36mmHg with an

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estimated aortic valve area of 0.81cm2.

The case was discussed at our combined multidisciplinary meeting. Estimated surgical mortality by STS score was 7.6%. In view of the patent mammary and

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radial grafts, complex anatomy, chronic lung disease and obesity, he was

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referred for TAVR.

Initial vascular computed tomography (CT) was undertaken to confirm situs inversus, a right sided aorta and suitable ilio-femoral artery anatomy to accommodate the transfemoral delivery catheter (Figure 1). Vascular CT also confirmed a left sided inferior vena cava draining in to the right atrium thus

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ensuring a right femoral vein pacing wire could be manipulated into the right ventricle. The coaxial imaging plane joining the basal attachment of the aortic cusps was determined. In this plane, the aortic annulus area was measured at

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the level of the basal attachment of the aortic cusps (613mm2, mean diameter of 28mm) and the optimal deployment angle defined as the angle bisecting

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the right sinus of valsalva in the coaxial imaging plane (14° right anterior oblique with 5°cranial angulation).

TAVR was then undertaken from the right femoral artery following placement of a 19F Edward’s arterial sheath. The patient was positioned and implantation equipment laid out in the standard fashion. The aortic valve was crossed by an Amplatzer Extra StiffTM wire (Boston Scientific) and balloon

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ACCEPTED MANUSCRIPT Good aortic valvuloplasty performed using a 25mm balloon (Edwards) under rapid ventricular pacing. At this point, prior to insertion into the arterial sheath, the Novaflex+ delivery system was rotated 180 degrees to leave the Edward’s

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logo orientated in a posterior direction (Figure 2C). Once advanced to the distal aortic arch, flexion was applied by clockwise rotation of the handle wheel in the standard fashion. Thus, the delivery system articulated towards

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the left side of the patient and advanced easily around the right sided aortic

arch (Figure 2D). A 29mm Edwards SAPIEN XT Heart valve was deployed

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under rapid pacing (Figure 2E). Subsequent aortogram and transesophageal echocardiography confirmed excellent and stable position with trivial aortic regurgitation (Figure 2F). The patient was discharged 6 days following the procedure without incident and remains well.

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Discussion

This case report provides the first published description of TAVR from the

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femoral approach in a patient with dextrocardia situs inversus. This condition is associated with a number of additional cardiac and vascular malformations

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(2). Vascular CT assessing aortic root, aortic arch and venous anatomy was essential to ensure that venous pacing and valve delivery were viable from the femoral route. In addition to sizing ot the valve prosthesis, CT images also provided a useful guide to the optimal screening angle for deployment which could be modified following aortography during the procedure. Unlike apical implantation, theatre orientation for a femoral approach was unchanged (3).

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ACCEPTED MANUSCRIPT Good Importantly, 180° rotation of the Novaflex+ Transfe moral SystemTM enabled

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delivery of the valve prosthesis around the right sided aortic arch.

Acknowledgements

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Informed consent was obtained from the patient for the submission and publication of this case report and associated images. Additional members of

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the TAVR team were; Dr John Sullivan, Dr Jeremy Wood, Dr Rob Perry, Dr Blaine Kent and Dr James Velianou.

Disclosure Statement

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The authors have no conflicts of interest related to this case report.

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ACCEPTED MANUSCRIPT Good Figure legends:

Figure 1: Vascular computed tomography outlining; (A) right sided cardiac

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chambers with tortuous patent RIMA graft (white arrowhead), (B) right sided aortic arch at the optimal angle of valve deployment and (C) aortic valve

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annulus dimensions.

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Figure 2: Novoflex+ Transfemoral delivery catheter; (A) normal orientation with the Edwards logo anterior (red arrowhead), (B) following standard articulation to the right, (C) inverted orientation with the Edwards logo posterior, (D) following articulation to the left to facilitate passage around right sided aortic arch. Fluoroscopy during implantation demonstrating; (E)

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positioning of the valve prosthesis with pacing wire highlighted (yellow arrowhead), (F) aortogram following deployment of Edwards Sapien 29mm

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valve.

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ACCEPTED MANUSCRIPT Good References

1. Webb JG, Wood DA. Current status of transcatheter aortic valve

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replacement. J Am Coll Cardiol. 2012;60(6):483-492.

2. Bohun CM, Potts JE, Casey BM, Sandor GG. A population-based study of cardiac malformations and outcomes associated with dextrocardia. Am J

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Cardiol. 2007;100(2):305-309.

3. Weich HS, van Wyk J, van Zyl W, Vivier R, Phillips A, Mabin T. First case

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of transapical implantation of an aortic valve in a patient with dextrocardia.

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Journal Of Cardiothoracic Surgery. 2012;7:24.

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