124. Double TAVR Valve Explants with Warm Arch Repair: A Novel Approach

Objective: TAVR has become the standard of care for patients with severe aortic stenosis and suitable anatomical features. However, an increasing number of reoperations after TAVR has been observed, particularly following the approval of TAVR for low-risk patients. In this context, there is a need to emphasize, at a societal level, the importance of appropriate patient selection to prevent future catastrophic clinical outcomes resulting from the misuse of TAVR technology. We recently introduced a novel, simplified approach called warm aortic arch repair, which eliminates the need for hypothermic circulatory arrest and avoids axillary or femoral cannulation.
Case Video Summary:
A 64-year-old female patient, who underwent an emergent TAVR procedure using a 26 mm self-expanding TAVR valve five years ago, presented with severe aortic stenosis due to structural valve degeneration. The initial TAVR procedure had been complicated by valve embolization, with the embolized valve being left in the aortic arch, followed by the successful implantation of a second TAVR valve of the same size. Computed tomography angiography revealed inadequate valve-to-coronary (VTC) and valve-to-aorta (VTA) distances, rendering the redo-TAVR option infeasible. Therefore, double TAVR valve explantation with redo surgical aortic valve replacement (SAVR) was considered. The procedure posed unique challenges due to the presence of the embolized TAVR valve extending from the mid-ascending aorta to the mid-aortic arch, which precluded standard arterial cannulation, aortic cross-clamping, or aortotomy. The standard setup for warm aortic arch repair involves the placement of arterial lines for the upper (right radial artery) and lower body (femoral artery), near-infrared spectroscopy (NIRS), sternotomy, and cardiopulmonary bypass with central aortic arch cannulation and standard venous cannulation. Normothermia is maintained throughout the procedure. The enclosed video highlights the critical steps in performing the warm aortic arch repair and redo SAVR. The patient's postoperative course was uneventful.
Conclusions:
The warm aortic arch repair technique is safe, versatile and reproducible without hypothermic circulatory arrest. It has evolved to become the standard approach in our practice for managing aortic pathologies that require hemiarch or partial arch repair.

Shinichi Fukuhara (1), (1) University Of Michigan, Ann Arbor, MI

D. Craig Miller

Commentator

Henry and Thelma Doelger Professor of Cardiovascular Surgery, Emeritus

Stanford University Medical School

Stanford, CA 94305

 

Shinichi Fukuhara

Case Video Presenter

Dr. Fukuhara is G. Michael Deeb, M.D. and Nancy Deeb Research Professor of Cardiac Surgery at University of Michigan. His specialties include aortic surgery, endovascular aortic repair and transcatheter valve therapy. He earned his medical degree from Keio University School of Medicine in Tokyo, Japan (2006), where he also received training in surgery (2009) and cardiovascular surgery (2010) with intense endovascular experience. After moving to the United States, he completed his general surgery residency at Beth Israel Medical Center, New York, NY (2014), cardiothoracic surgery residency at Columbia University Medical Center, New York, NY (2016), aortic surgery fellowship at University of Pennsylvania, Philadelphia, PA (2017). He is board certified by the American Board of Surgery, the American Board of Thoracic Surgery and the Japan Surgical Society.