1 July, 2024

Transcatheter Aortic Valve Replacement in a Frail Octogenarian with Complex Anatomy: A Case Study

 

In this blog, we share an inspiring and challenging case of transcatheter aortic valve replacement (TAVR) performed on a very frail, octogenarian patient with multiple comorbidities and complex anatomical challenges. This case underscores the potential of TAVR to offer a lifeline to patients who are not candidates for traditional surgery.

Patient Background

Our patient, an 85-year-old female, presented with a constellation of symptoms and conditions:

  • Heart failure symptoms
  • Atrial fibrillation
  • Severe calcific aortic stenosis
  • Moderate mitral regurgitation
  • Moderate pulmonary hypertension
  • Ascending aortic aneurysm

In addition to these conditions, the patient’s anatomical complexities included:

  • Tortuous iliac arteries
  • Ascending aortic aneurysm with extensive calcification
  • Horizontal aorta

Given her age, frailty, and the prohibitively high surgical risk, traditional open-heart surgery was deemed unsuitable.

Decision-Making Process

After thorough discussions within the heart team and with the patient and her family, a shared decision was made to proceed with TAVR. The aim was to provide symptomatic relief and improve the quality of life without subjecting the patient to the risks associated with open-heart surgery.

The Procedure

The procedure was carried out under general anesthesia (GA) with real-time transesophageal echocardiography (TEE) guidance to monitor for any potential aortic injury. The 23 mm Myval valve was selected for deployment, given its suitability for the patient’s anatomical and clinical profile.

Key procedural details include:

  • Careful navigation through tortuous iliac arteries
  • Precise placement of the Myval valve despite extensive calcification and the horizontal orientation of the aorta
  • Continuous TEE guidance to ensure accurate deployment and to avoid aortic injury

Post-Procedure Outcome

The procedure was completed successfully, with several positive outcomes:

  • No paravalvular leak (PVL)
  • No significant conduction disturbances
  • A mean gradient of 4 mmHg post-procedure
  • The patient experienced an uneventful recovery

Conclusion

This case highlights the transformative potential of TAVR for high-risk patients with complex medical and anatomical profiles. The successful deployment of the Myval valve in this frail octogenarian with multiple comorbidities and challenging anatomy demonstrates that, with meticulous planning and expert execution, TAVR can offer a safe and effective alternative to conventional surgery.

As we continue to advance in the field of interventional cardiology, cases like this reinforce the importance of a multidisciplinary approach and shared decision-making in achieving optimal patient outcomes.

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