Preventing brain embolism by using a modified isolation technique in transcatheter aortic valve implantation for a patient with shaggy and porcelain aorta

Abstract

Transcatheter aortic valve implantation (TAVI) has become a useful and effective treatment for surgical high-risk patients with severe aortic valve stenosis (AS). Stroke is one of the most frequent complications associated with TAVI. Shaggy and porcelain aortas are a risk factor for procedure-related strokes. Preventing brain embolism is one of the most important goals in patients with diseased aortas. We present a case where we performed TAVI in an 89-year-old man with severe AS, a shaggy aorta, a porcelain aorta, and congestive heart failure. TAVI via a transfemoral approach was performed using a modified isolation technique with cannulation from bilateral axillary arteries and cardiopulmonary bypass to prevent brain embolism. The catheter-delivered embolic protection device is necessary to pass the diseased aorta, but the modified isolation technique can be used without any contact with the shaggy aorta. Embolism did not occur, and his heart failure improved immediately. <Learning objective: Transcatheter aortic valve implantation (TAVI) is a therapeutic option for patients with severe aortic stenosis considered to be at high risk for aortic valve replacement. Cerebral embolism is the most frequent complication of TAVI. A shaggy or porcelain aorta is associated with a high risk of stroke during TAVI. We report a case of TAVI in a shaggy and porcelain aorta and prevention of cerebral embolism by adopting a modified isolation technique without using conventional protection devices.>.

Keywords: Porcelain aorta; Shaggy aorta; Transcatheter aortic valve implantation.

Fig. 1

Preoperative echocardiography. (A) Echocardiographic examination before treatment showed aortic valve stenosis in the parasternal long-axis view. (B) A moderate amount of mitral regurgitation was observed in the four-chamber view.

Fig. 2

Preoperative computed tomography (CT). (A) The CT axial and sagittal image showed thrombus in the ascending aorta and the aortic arch, and this was finding of shaggy aorta. (B) The aorta generally showed a high degree of calcification, a finding of porcelain aorta.

Fig. 3

Photograph of the operative setup. The cardiopulmonary bypass machine was positioned behind the monitor, and to the left side of the patient. The anesthesia apparatus and transesophageal echocardiography machine were placed near the patient’s head.