Percutaneous balloon aortic valvuloplasty in different age groups

Intervention for critical aortic stenosis in Hutchinson-Gilford progeria syndrome

Hutchinson-Gilford Progeria Syndrome (HGPS) is an ultra-rare genetic premature aging disease that is historically fatal in teenage years, secondary to severe accelerated atherosclerosis. The only approved treatment is the farnesyltransferase inhibitor lonafarnib, which improves vascular structure and function, extending average untreated lifespan of 14.5 years by 4.3 years (30%). With this longer lifespan, calcific aortic stenosis (AS) was identified as an emerging critical risk factor for cardiac death in older patients. Intervention to relieve critical AS has the potential for immediate improvement in healthspan and lifespan. However, HGPS patient-device size mismatch, pervasive peripheral arterial disease, skin and bone abnormalities, and lifelong failure to thrive present unique challenges to intervention. An international group of experts in HGPS, pediatric and adult cardiology, cardiac surgery, and pediatric critical care convened to identify strategies for successful treatment. Candidate procedures were evaluated by in-depth examination of 4 cases that typify HGPS clinical pathology. Modified transcatheter aortic valve replacement (TAVR) and left ventricular Apico-Aortic Conduit (AAC) placement were deemed high risk but viable options. Two cases received TAVR and 2 received AAC post-summit. Three were successful and 1 patient died perioperatively due to cardiovascular disease severity, highlighting the importance of intervention timing and comparative risk stratification. These breakthrough interventions for treating critical aortic stenosis in HGPS patients could rewrite the current clinical perspective on disease course by greatly improving late-stage quality of life and increasing lifespan. Expanding worldwide medical and surgical competency for this ultra-rare disease through expert information-sharing could have high impact on treatment success.

Ultrasound-Guided Percutaneous Balloon Aortic Valvuloplasty for Aortic Stenosis

Percutaneous balloon aortic valvuloplasty (PBAV), which is used to treat symptomatic aortic stenosis, requires ionizing radiation and contrast agent for imaging guidance. The aim of the study is to evaluate the feasibility and effectiveness of ultrasound-guided PBAV in patients with aortic stenosis. This case series included 30 patients (14 males; mean age, 61.5 ± 4.5 years) with moderate/severe aortic stenosis treated with ultrasound-guided PBAV at the Ultrasound Department, Fuwai Hospital, Beijing, China, between January 2016 and July 2019. Cardiac function (New York Heart Association grade) was assessed before PBAV and 1 month after the procedure. Aortic peak jet velocity, aortic valve orifice area (AVA), mean transvalvular pressure gradient (MTPG), left ventricular end-diastolic diameter (LVDD), left ventricular ejection fraction (LVEF), and left ventricular end-systolic diameter (LVESD) were determined before and immediately after PBAV using Doppler echocardiography. Preprocedural cardiac function was grade I in 3 cases, grade II in 9 cases, grade III in 10 cases, and grade IV in 8 cases. Postprocedural cardiac function was grade I in 22 cases, grade II in 4 cases, and grade III in 4 cases, suggesting that cardiac function was improved by PBAV. Ultrasound-guided PBAV resulted in significant improvements (P < 0.05) in aortic peak jet velocity (3.68 ± 0.811 m/s vs. 4.79 ± 0.63 m/s), MTPG (33.77 ± 13.85 mmHg vs. 54.54 ± 13.81 mmHg), AVA (1.96 ± 0.25 cm² vs. 0.98 ± 0.12 cm²), LVEDD (51.90 ± 3.21 mm vs. 65.60 ± 6.81 mm), LVEF (63.46 ± 11.29% vs. 56.31 ± 11.04%), and LVESD (35.50 2.62 mm vs. 45.20 ± 2.42 mm). Ultrasound-guided PBAV is feasible and achieves good short-term effects in patients with aortic stenosis.

Aortic stenosis complicated by cardiogenic shock treated by transcatheter aortic valve replacement with extracorporeal membrane oxygenation: A case report

RATIONALE

Cardiogenic shock secondary to aortic stenosis (AS) is a challenging problem owing to the high mortality associated with treatment, and successful treatment of such patients has been rare.

PATIENT CONCERNS

A 77-year-old man presented with exercise intolerance and progressive exertional dyspnea and chest pain. The patient was suffered from cardiogenic shock after percutaneous coronary intervention.

DIAGNOSIS

He was diagnosed by transthoracic echocardiography (TTE) and coronary angiogram. His main diagnose was AS and coronary artery disease.

INTERVENTION

The patient received venoarterial extracorporeal membrane oxygenation (VA-ECMO) and transcatheter aortic valve replacement (TAVR).

OUTCOME

As of the 5-month follow-up, the patient was well, and capable of basic independent living. The TTE suggested that the left ventricular end-diastolic volume had decreased from 66 to 45 mm and the left ventricular ejection fraction had risen from 20% to 50%.

LESSONS

Patients with cardiogenic shock secondary to AS are very difficult to treat medically. ECMO with TAVR may be a reasonable strategy.