Case report: Self-expanding transcatheter valve implantation (Acurate Neo 2) in a very small native aortic annulus

Figures

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  Figure 1. (A) Transthoracic echocardiography (TTE) 5-chamber view showing increased peak and medium transvalvular aortic pressure gradient of, respectively, 75 mmHg and 43 mmHg. (B)Transesophageal echocardiography (TEE) showing a tricuspid aortic valve with severe stenosis and a planimetric aortic valve area of 0,5 cm2. LA, left atrium; RA, right atrium; RV, right ventricle. (C) TEE showing a mild mitral valvular insufficiency with neither significant subvalvular and/or intraventricular pressure gradient nor evidence of systolic anterior motion (SAM) of the anterior leaflet of the mitral valve. (D) Invasive simultaneous registration of left ventricular (LV) and aortic pressures showing a significant transvalvular pressure gradient during the ventricular ejection period. LV pressure exceeds the aortic pressure (gray area, pressure gradient generated by valvular stenosis). The LV peak systolic pressure during ejection ranged between 152 to 156 mmHg and the aortic pressure between 102 to 106 mmHg. No elevated LV telediastolic pressure was documented.).

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  Figure 2. (A) Pre-operative thoraco-abdominal computed tomography (CT) images were analyzed using 3mensio Structural Heart software (Pie Medical Imaging, Netherlands): the aortic annulus perimeter was 51.7 mm (minor annulus diameter 15.1 mm, major annulus diameter 18.2 mm) and the area was 207,8 mm2. (B) Pre-operative thoraco-abdominal CT images showed a tricuspid aortic valve without significant valvular calcifications (images reconstructed with OsiriX DICOM Viewer Pixmeo SARL, Switzerland). (C) Pre-operative thoraco-abdominal CT images showed a LVOT perimeter of 45.3 mm with elliptical shape (minor annulus diameter 11.5 mm, major annulus diameter 16.5 mm) and an area of 149,9 mm2 (images reconstructed with 3mensio Structural Heart software). (D and E) CT images showing the distance from the virtual basal ring (VBR) to left main trunk of 8.3 mm (see D) and to the right coronary artery of 14.9 mm (see E). (F) Pre-operative thoraco-abdominal CT images showing the heart chambers and the ascending aorta according to the ‘double oblique virtual reality’ reconstruction with 3mensio Structural Heart software. Asc Ao, Ascending Aorta; IVS, interventricular septum; LM, left main coronary trunk;…

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  Figure 3. (A) Basal aortography in the “virtual basal plane” view (LAO 5°−10° cranial projection). (B) Final aortography documenting correct implantation of an Acurate Neo 2 small-size valve with patent coronary arteries and correct minimal LVOT protrusion of the THV to ensure anchoring without any trace of paravalvular leak. (C) Preprocedural images of CT angiography with tridimensional reconstruction of the aortic valve showing a tricuspid aortic valve. The yellow dot identifies the non-coronary cusp, the red dot identifies the left coronary cusp, and the green dot identifies the right coronary cusp. (D–F) Preprocedural images of CT angiography with tridimensional reconstruction of the aortic valve showing a tricuspid aortic valve without significant calcific degeneration and left and right ventricular chambers. In Panel (D), the yellow dot identifies the non-coronary cusp, the red dot identifies the left coronary cusp, and the green dot identifies the right coronary cusp.