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Valve-in-valve transcatheter aortic valve replacement in a young patient with a suspected COVID-19 infection: a surgical dilemma in the era of the COVID-19 pandemic
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abstract
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Abstract
We report on a case of a 57-year-old male patient, who underwent full root replacement in 2005 and now presented with high grade aortic insufficiency. On admission, the patient underwent a computed tomography scan which demonstrated interstitial infiltration in the left lung, highly suspicious for a COVID-19 infection that could not be confirmed by reverse transcription polymerase chain reaction (RT-PCR) testing. As there usually is a delay between infection and positive RT-PCR test results, the initial decision was to perform additional testing. However, the patient deteriorated quickly in spite of optimal medical therapy making urgent aortic valve replacement necessary. We decided to perform transcatheter aortic valve replacement to avoid cardiopulmonary bypass with shorter operative times, presumably shorter ventilation times and duration of intensive care unit stay, and thus a lesser risk for pulmonary complications.
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title
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Abstract
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We report on a case of a 57-year-old male patient, who underwent full root replacement in 2005 and now presented with high grade aortic insufficiency. On admission, the patient underwent a computed tomography scan which demonstrated interstitial infiltration in the left lung, highly suspicious for a COVID-19 infection that could not be confirmed by reverse transcription polymerase chain reaction (RT-PCR) testing. As there usually is a delay between infection and positive RT-PCR test results, the initial decision was to perform additional testing. However, the patient deteriorated quickly in spite of optimal medical therapy making urgent aortic valve replacement necessary. We decided to perform transcatheter aortic valve replacement to avoid cardiopulmonary bypass with shorter operative times, presumably shorter ventilation times and duration of intensive care unit stay, and thus a lesser risk for pulmonary complications.
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CASE REPORT
A 57-year-old male with history of a full root replacement with a 29-mm Medtronic Freestyle prosthesis in 2005 was admitted to our institution. The patient had severe aortic insufficiency with progredient symptoms of dyspnoea in the last 2 weeks, with a proBNP of 1459 pg/ml and a C reactive protein of 22.8 mg/l at admission. All other laboratory parameters were normal. The preoperative computed tomography (CT) scan showed interstitial infiltration of the left lung that was considered highly suspicious for a COVID-19 infection by three different radiologists [1] (Fig. 1). Additionally, the patient had pleural effusion indicating impending cardiac decompensation (Fig. 2). The patient was tested twice with PCR for COVID-19, but both tests returned negative. As the patient was initially clinically stable under medication, it was decided to postpone further surgical therapy for 2 weeks to in order to perform consecutive repeated testing for COVID-19 infection to safely confirm or rule out infection. Two days later, the patient was readmitted with severe symptoms of heart failure and an increase in N-terminal pro-B-type natriuretic peptide levels to 1646 pg/ml. It was not completely clear if the symptoms including interstitial infiltration had resulted from a COVID-19 infection or from a progression of symptoms from the high-grade aortic insufficiency, or even both. After consulting with the patient, it was decided to perform a transfemoral valve-in-valve implantation with a 29-mm Edwards SAPIEN S3 valve. In adherence to all safety precautions recommended so far, including N95-respirators, the procedure was successfully performed the day after the readmission of the patient. The patient recovered well from the procedure. During the whole hospital stay, it was assumed that the patient was COVID-19-positive, as we could not completely rule out infection. The patient consented to having his information disclosed in this case report.
Figure 1: Computed tomography scan on admission with interstitial infiltration highly suspicious for a COVID-19 infection.
Figure 2: Computed tomography scan with pleural effusion.
DISCUSSION
In the current COVID-19-pandemic, it is important to rule out an infection with COVID-19 in patients undergoing cardiac surgery to prevent complications from COVID-19 infection for a variety of reasons—for example, there is currently no available information on how these patients tolerate cardiopulmonary bypass. For this reason and to ensure the availability of intensive care unit (ICU) beds, most countries recommend postponing elective surgeries or interventions as much as possible. In our patient, the CT scan with interstitial infiltration was highly suspicious for a COVID-19 infection that was confirmed by three independent radiologists. In contrast, two consecutive PCR tests returned negative. Recently, it has been discussed that PCR testing might be inferior to CT scans to detect infections as the average time between initial negative and positive reverse transcription polymerase chain reaction test results in patients who already display signs of infection on CT scans is 5.1 ± 1.5 days [2].
In the patient described above, our dilemma was that clinical symptoms, increasing bilateral pleural effusion and a rise in proBNP indicated impending cardiac failure. At the same time, COVID-19-associated pneumonia was still a possibility. As the intended waiting interval of 2 weeks to increase certainty concerning the infectious state could not be achieved due to the patient’s cardiac condition, immediate treatment was necessary. Following discussion in the local heart team and with the consent of the patient, we decided to perform valve-in-valve transcatheter aortic valve replacement (TAVR) to prevent the potential complications of a prolonged re-root-replacement with its long operative and cardiopulmonary bypass times, which could lead to an increased time on the respirator in the ICU. The decision was made even though the patient was only 57 years old and would have undergone an open surgical procedure under normal circumstances, especially as there is limited information available on the durability of TAVR valves [3]. Due to our extensive experience with valve-in-valve-TAVR into degenerated Freestyle-prostheses (>40 cases), we decided to use a SAPIEN S3 (Edwards Lifesciences Corp. Irvine, CA, USA), which facilitates reoperation and preserves the access to the coronary arteries, which is of importance in a young patient. We also decided to perform the procedure under general anaesthesia and to intubate the patient as we intended to perform intraoperative transoesophageal echocardiography and wanted to avoid the risk of an emergency intubation during the procedure, which would pose a higher risk of infection for the whole team than an intubation under normal conditions.
CONCLUSION
At the moment, we believe that any patient requiring urgent cardiac intervention or surgery with a reasonable suspicion of COVID-19 should be assumed to be infectious. A less invasive treatment might be preferable to prevent potential complications. However, any treatment strategy in challenging situations like these should be based on the decision of the Heart Team comprising surgeons, cardiologists, anaesthesiologists and intensivists. Withholding or delaying treatment in a patient with a life-threatening condition on the basis of a possible or confirmed COVID-19-infection should not be an option.
Conflict of interest: none declared.
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CASE REPORT
A 57-year-old male with history of a full root replacement with a 29-mm Medtronic Freestyle prosthesis in 2005 was admitted to our institution. The patient had severe aortic insufficiency with progredient symptoms of dyspnoea in the last 2 weeks, with a proBNP of 1459 pg/ml and a C reactive protein of 22.8 mg/l at admission. All other laboratory parameters were normal. The preoperative computed tomography (CT) scan showed interstitial infiltration of the left lung that was considered highly suspicious for a COVID-19 infection by three different radiologists [1] (Fig. 1). Additionally, the patient had pleural effusion indicating impending cardiac decompensation (Fig. 2). The patient was tested twice with PCR for COVID-19, but both tests returned negative. As the patient was initially clinically stable under medication, it was decided to postpone further surgical therapy for 2 weeks to in order to perform consecutive repeated testing for COVID-19 infection to safely confirm or rule out infection. Two days later, the patient was readmitted with severe symptoms of heart failure and an increase in N-terminal pro-B-type natriuretic peptide levels to 1646 pg/ml. It was not completely clear if the symptoms including interstitial infiltration had resulted from a COVID-19 infection or from a progression of symptoms from the high-grade aortic insufficiency, or even both. After consulting with the patient, it was decided to perform a transfemoral valve-in-valve implantation with a 29-mm Edwards SAPIEN S3 valve. In adherence to all safety precautions recommended so far, including N95-respirators, the procedure was successfully performed the day after the readmission of the patient. The patient recovered well from the procedure. During the whole hospital stay, it was assumed that the patient was COVID-19-positive, as we could not completely rule out infection. The patient consented to having his information disclosed in this case report.
Figure 1: Computed tomography scan on admission with interstitial infiltration highly suspicious for a COVID-19 infection.
Figure 2: Computed tomography scan with pleural effusion.
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title
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CASE REPORT
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p
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A 57-year-old male with history of a full root replacement with a 29-mm Medtronic Freestyle prosthesis in 2005 was admitted to our institution. The patient had severe aortic insufficiency with progredient symptoms of dyspnoea in the last 2 weeks, with a proBNP of 1459 pg/ml and a C reactive protein of 22.8 mg/l at admission. All other laboratory parameters were normal. The preoperative computed tomography (CT) scan showed interstitial infiltration of the left lung that was considered highly suspicious for a COVID-19 infection by three different radiologists [1] (Fig. 1). Additionally, the patient had pleural effusion indicating impending cardiac decompensation (Fig. 2). The patient was tested twice with PCR for COVID-19, but both tests returned negative. As the patient was initially clinically stable under medication, it was decided to postpone further surgical therapy for 2 weeks to in order to perform consecutive repeated testing for COVID-19 infection to safely confirm or rule out infection. Two days later, the patient was readmitted with severe symptoms of heart failure and an increase in N-terminal pro-B-type natriuretic peptide levels to 1646 pg/ml. It was not completely clear if the symptoms including interstitial infiltration had resulted from a COVID-19 infection or from a progression of symptoms from the high-grade aortic insufficiency, or even both. After consulting with the patient, it was decided to perform a transfemoral valve-in-valve implantation with a 29-mm Edwards SAPIEN S3 valve. In adherence to all safety precautions recommended so far, including N95-respirators, the procedure was successfully performed the day after the readmission of the patient. The patient recovered well from the procedure. During the whole hospital stay, it was assumed that the patient was COVID-19-positive, as we could not completely rule out infection. The patient consented to having his information disclosed in this case report.
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Figure 1: Computed tomography scan on admission with interstitial infiltration highly suspicious for a COVID-19 infection.
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Figure 1:
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Computed tomography scan on admission with interstitial infiltration highly suspicious for a COVID-19 infection.
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Computed tomography scan on admission with interstitial infiltration highly suspicious for a COVID-19 infection.
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Figure 2: Computed tomography scan with pleural effusion.
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Figure 2:
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Computed tomography scan with pleural effusion.
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Computed tomography scan with pleural effusion.
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DISCUSSION
In the current COVID-19-pandemic, it is important to rule out an infection with COVID-19 in patients undergoing cardiac surgery to prevent complications from COVID-19 infection for a variety of reasons—for example, there is currently no available information on how these patients tolerate cardiopulmonary bypass. For this reason and to ensure the availability of intensive care unit (ICU) beds, most countries recommend postponing elective surgeries or interventions as much as possible. In our patient, the CT scan with interstitial infiltration was highly suspicious for a COVID-19 infection that was confirmed by three independent radiologists. In contrast, two consecutive PCR tests returned negative. Recently, it has been discussed that PCR testing might be inferior to CT scans to detect infections as the average time between initial negative and positive reverse transcription polymerase chain reaction test results in patients who already display signs of infection on CT scans is 5.1 ± 1.5 days [2].
In the patient described above, our dilemma was that clinical symptoms, increasing bilateral pleural effusion and a rise in proBNP indicated impending cardiac failure. At the same time, COVID-19-associated pneumonia was still a possibility. As the intended waiting interval of 2 weeks to increase certainty concerning the infectious state could not be achieved due to the patient’s cardiac condition, immediate treatment was necessary. Following discussion in the local heart team and with the consent of the patient, we decided to perform valve-in-valve transcatheter aortic valve replacement (TAVR) to prevent the potential complications of a prolonged re-root-replacement with its long operative and cardiopulmonary bypass times, which could lead to an increased time on the respirator in the ICU. The decision was made even though the patient was only 57 years old and would have undergone an open surgical procedure under normal circumstances, especially as there is limited information available on the durability of TAVR valves [3]. Due to our extensive experience with valve-in-valve-TAVR into degenerated Freestyle-prostheses (>40 cases), we decided to use a SAPIEN S3 (Edwards Lifesciences Corp. Irvine, CA, USA), which facilitates reoperation and preserves the access to the coronary arteries, which is of importance in a young patient. We also decided to perform the procedure under general anaesthesia and to intubate the patient as we intended to perform intraoperative transoesophageal echocardiography and wanted to avoid the risk of an emergency intubation during the procedure, which would pose a higher risk of infection for the whole team than an intubation under normal conditions.
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title
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DISCUSSION
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p
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In the current COVID-19-pandemic, it is important to rule out an infection with COVID-19 in patients undergoing cardiac surgery to prevent complications from COVID-19 infection for a variety of reasons—for example, there is currently no available information on how these patients tolerate cardiopulmonary bypass. For this reason and to ensure the availability of intensive care unit (ICU) beds, most countries recommend postponing elective surgeries or interventions as much as possible. In our patient, the CT scan with interstitial infiltration was highly suspicious for a COVID-19 infection that was confirmed by three independent radiologists. In contrast, two consecutive PCR tests returned negative. Recently, it has been discussed that PCR testing might be inferior to CT scans to detect infections as the average time between initial negative and positive reverse transcription polymerase chain reaction test results in patients who already display signs of infection on CT scans is 5.1 ± 1.5 days [2].
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p
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In the patient described above, our dilemma was that clinical symptoms, increasing bilateral pleural effusion and a rise in proBNP indicated impending cardiac failure. At the same time, COVID-19-associated pneumonia was still a possibility. As the intended waiting interval of 2 weeks to increase certainty concerning the infectious state could not be achieved due to the patient’s cardiac condition, immediate treatment was necessary. Following discussion in the local heart team and with the consent of the patient, we decided to perform valve-in-valve transcatheter aortic valve replacement (TAVR) to prevent the potential complications of a prolonged re-root-replacement with its long operative and cardiopulmonary bypass times, which could lead to an increased time on the respirator in the ICU. The decision was made even though the patient was only 57 years old and would have undergone an open surgical procedure under normal circumstances, especially as there is limited information available on the durability of TAVR valves [3]. Due to our extensive experience with valve-in-valve-TAVR into degenerated Freestyle-prostheses (>40 cases), we decided to use a SAPIEN S3 (Edwards Lifesciences Corp. Irvine, CA, USA), which facilitates reoperation and preserves the access to the coronary arteries, which is of importance in a young patient. We also decided to perform the procedure under general anaesthesia and to intubate the patient as we intended to perform intraoperative transoesophageal echocardiography and wanted to avoid the risk of an emergency intubation during the procedure, which would pose a higher risk of infection for the whole team than an intubation under normal conditions.
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sec
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CONCLUSION
At the moment, we believe that any patient requiring urgent cardiac intervention or surgery with a reasonable suspicion of COVID-19 should be assumed to be infectious. A less invasive treatment might be preferable to prevent potential complications. However, any treatment strategy in challenging situations like these should be based on the decision of the Heart Team comprising surgeons, cardiologists, anaesthesiologists and intensivists. Withholding or delaying treatment in a patient with a life-threatening condition on the basis of a possible or confirmed COVID-19-infection should not be an option.
Conflict of interest: none declared.
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title
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CONCLUSION
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p
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At the moment, we believe that any patient requiring urgent cardiac intervention or surgery with a reasonable suspicion of COVID-19 should be assumed to be infectious. A less invasive treatment might be preferable to prevent potential complications. However, any treatment strategy in challenging situations like these should be based on the decision of the Heart Team comprising surgeons, cardiologists, anaesthesiologists and intensivists. Withholding or delaying treatment in a patient with a life-threatening condition on the basis of a possible or confirmed COVID-19-infection should not be an option.
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Conflict of interest: none declared.
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