Successful TAVI case using the BAV as bridge to TAVI in

Successful TAVI case using the BAV as bridge to TAVI in severe AS patient with very high risk

Sejong General HospitalCheol Woong Yu, MD, PhD

2010 Sejong Cardiovascular Symposium

Case 1• M/68• CC: DOE Fc III~IV (onset; 1 months ) and

cardiogenic shock, altered mentality.• P.I.; He was undergoing HF therapy due to

severe AS at other hospital but transferred to our hospital because of aggravation of HF and unstable condition.

• P/Hx; HTN, CHF (since 1 year ago), heavy alcoholics

• No prev cardiac surgery, No bypassed vessel


Lab findings

• V/S BP 80/55, RR 32, • Renal function: Ccr 30ml/min (B/Cr

98/2.55)• AST/ALT 1879/1777, TB 2.7, uric acid;22.8• INR 2.09• Troponin T;0.299, ProBNP;33325, CK-

MB;31.9• ABGA;PH 7.456-PCO2 20.6-PO2 101.6- BE -

6.6• CBC;WBC 19.5 Hg 12.9(MCV74.4, MCH

25.4)-Plt 197K


Chest X ray


Transthoracic Echocardiography



Moderate to severe LV systolic dysfunctionModerate MR, LVE, LAE,



• LV 68/58mm, EF 31%, AVA=0.7cm2 by CE• AV peak/mean PG=93/63mmHg


Very high risk patient

• Severe AS with severe LV systolic dysfx, mod MR

• CHF with pul edema, • cardiogenic shock• ARF on CKD• Congestive hepatopathy• LC(?)

• Logistic Euroscore; 74% STS; 18%


The next day…

• The patient was more aggravated..

• -> BP 70/40..and anuria, azotemia, mental change despite of use of all inotropics

What should I do at this situation?


Can the BAV be troubleshooter for this crucial moment?

Z-med 22x30mm,superstiff Amplatz 035 wire, 4atm


Can the BAV be troubleshooter for this crucial moment?


Hemodynamic tracing during BAV


Post BAV TTE• LV 70/53mm, EF 40% (<-30%), AVA=1.1cm2 (<-0.7)• AV peak/mean PG=99/63mmHg•(<- 93/63mmHg)• Mod to severe AR


PostBAV course…

• V/S stable, 80~60/40~55 -> 120/70• Mental alert• CRRT apply-> azotemia improved• LFT improved

3 days later, sudden cardiac arrest developed and the patient died !!


Case 2• M/77• CC: DOE Fc III~IV (onset; 2 months )• P.I.; He was undergoing TACE therapy due to

HCC at other hospital and developed CHF during that therapy. So, he was transferred to our hospital because of aggravation of HF after diagnosis of severe AS

• P/Hx; HTN, DM, recent stroke, HCC (7 times TACE) , radiation pneumonitis(?)

• NO prev cardiac surgery, No bypassed vessel


Lab findings

• V/S BP 131/63, RR 42 • Renal function: normal• LFT;normal• PFT; mild obstructive lung disease• ABGA;PH 7.457-PCO2 38.5-PO2 61.6- BE 4.0• CBC;WBC 4860 Hg 11.1(MCV 98.0, MCH

33.2)-Plt 189K


Chest X ray and EKG

A.Fib with complete AV block


TTEAVA=0.74/0.6 by CE/Planimetry, Peak/Mean PG=129/71 mmHgPeak V;5.7m/s, EF=79%, mild to mod AR, MR, TR, PA pr;58mmHg


What is the next step ?..

Permanent pacemaker implantation

After PM implantation , the patient continuely complained of dyspnea and orthopnea…

BAV..?


BAV…

TYSHAK 23x30mm, Amplatzer superstiff 035x26020% contrast, 2 atm x3


Hemodynamic tracing between pre and post BAV

Mean PG: 83 -> 51mmHg


Post BAV TTEAVA=0.95cm2 (<-0.74), Peak/Mean PG=101/59 mmHg(<-129/71)Peak V;5m/s, EF=79%, mild AR , MR, TR, PA pr;73mmHg


Post BAV clinical course..

Pleural effusion remained but symptomatically stable


2 weeks after BAV, TAVI was safely performed

AP Caudal 11.2 Ascendra balloon 26mm


2 weeks after BAV, TAVI was safely performed

Edwards SAPIEN THV 26mm TEE finding; optimal implantation


Post TAVI TEE


Post TAVI TTEAV peak/mean PG=17.5/9.5mmHg


Post TAVI clinical course

No further pleural effusion V/S stableNo orthopnea, N dyspneaImproved functional capacity

Take home message

•BAV can play an important role, such as bridge to TAVI, especially in very high risk patient.

•To achieve optimal BAV result as a bridge role and to avoid complication associated with BAV procedure, further studies is needed , such as about optimal balloon size, inflation pressure, postBAV pr gradient, and so on.

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Successful TAVI case using the BAV as bridge to TAVI in