Safety and Effectiveness of Combined Percutaneous Coronary Angioplasty and Aortic Valvuloplasty in An Elderly Patient with Cardiogenic Shock: Effect on Concomitant Severe Mitral Regurgitation
An 80-year-old diabetic man with severe aortic stenosis was admitted to our hospital for cardiogenic shock complicating non-ST-elevation myocardial infarction. Echocardiographic evaluation showed also a severe degree of both left ventricular dysfunction and mitral regurgitation. The patient was initially stabilized with inotropes and mechanical ventilation was necessary because of concurrent pulmonary edema. The day after, he was submitted to coronary angiography showing bivessel coronary disease. Given the high estimated operative risk, the patient was treated with angioplasty and bare metal stent implantation on both right coronary and circumflex artery; contemporarily, balloon aortic valvuloplasty (BAV) was performed with anterograde technique, obtaining a significant increase in planimetric valve area and reduction in transvalvular peak gradient. Few days after the procedure echocardiogram showed an increase in left ventricular ejection fraction, moderate aortic stenosis with mild regurgitation and moderate mitral regurgitation. Hemodynamic and clinical stabilization were also obtained, allowing amine support discontinuation and weaning from mechanical ventilation. At three months follow-up, the patient reported a further clinical improvement from discharge, and echocardiographic evaluation showed moderate aortic stenosis and an additional increase in left ventricular function and decrease in mitral regurgitation degree. In conclusion, combined BAV and coronary angioplasty were associated in our patient with hemodynamic and clinical stabilization as well as with a significant reduction in transvalvular aortic gradient and mitral regurgitation and an increase in left ventricular ejection fraction both in-hospital and at three month follow-up; this case suggests that these procedures are feasible even in hemodynamically unstable patients and are associated with a significant improvement in quality of life.
Rosenhek R, Maurer G, Baumgartner H. Should early elective surgery be performed in patients with severe but asymptomatic aortic stenosis. Eur Heart J 2002;23(18):1417-21.
Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS. Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly. N Engl J Med 1999;341(3):142-7.
Kolh P, Kerzmann A, Lahaye L, Gerard P, Limet R. Cardiac surgery in octogenarians; peri-operativeoutcome and long-term results. Eur Heart J 2001;22(14):1235-43.
Scott WC, Miller DC, Haverich A, Dawkins K, Mitchell RS, Jamieson SW, Oyer PE, Stinson EB, Baldwin JC, Shumway NE. Determinants of operative mortality for patients undergoing aortic valve replacement. Discriminant analysis of 1,479 operations. J Thorac Cardiovasc Surg 1985;89(3):400-13.
Whisenant B, Sweeney J, Ports TA. Combined PTCA and aortic valvuloplasty for acute myocardial,infarction complicated by severe aortic stenosis and cardiogenic shock. Cathet Cardiovasc Diag 1997;42(3):283-5.
Kato K, Sato N, Fujita N, Yamamoto T, Iwasaki YK, Yodogawa K, Takayama M, Tanaka K, Takano T. Combined therapy with percutaneous coronary intervention and percutaneous aortic valvuloplasty under mechanical support for an elderly patient with cardiogenic shock. J Nippon Med Sch 2006;73(3):158-63.
Cribier A, Savin T, Saoudi N, Rocha P, Berland J, Letac B. Percutaneous transluminal valvuloplasty of acquired aortic stenosis in elderly patients: an alternative to valve replacement? Lancet 1986;1(8472):63-7.
Conradi L, Reichenspurner H. Review on balloon aortic valvuloplasty: a surgeon’s perspective in 2008. Clin Res Cardiol 2008;97(5):285-7.
Otto CM, Mickel MC, Kennedy JW, Alderman EL, Bashore TM, Block PC, Brinker JA, Diver D, Ferguson J, Holmes DR Jr, et al. Three-year outcome after balloon aortic valvuloplasty. Insights into prognosis of valvular aortic stenosis. Circulation 1994;89(2):642-50.
American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease); Society of Cardiovascular Anesthesiologists, Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the ciety of Thoracic Surgeons. J Am Coll Cardiol 200 ;48(3):e1-148.
[No authors listed]. Percutaneous balloon aortic valvuloplasty. Acute and 30-day follow-up results in 674 patients from the NHLBI Balloon Valvuloplasty Registry. Circulation 1991;84(6):2383-97.
Sack S, Kahlert P, Khandanpour S, Naber C, Philipp S, Möhlenkamp S, Sievers B, Kälsch H, Erbel R. Revival of an old method with new techniques: balloon aortic valvuloplasty of the calcified aortic stenosis in the elderly. Clin Res Cardiol 2008;97(5):288-97.
Eisenhauer AC, Hadjipetrou P, Piemonte TC. Balloon aortic valvuloplasty revisited: the role of the inoue balloon and transseptal antegrade approach. Cathet Cardiovasc Interv 2000;50(4):484-91.
Cubeddu RJ, Jneid H, Don CW, Witzke CF, Cruz- Gonzalez I, Gupta R, Rengifo-Moreno P, Maree AO, Inglessis I, Palacios IF. Retrograde Versus Antegrade Percutaneous Aortic Balloon Valvuloplasty: immediate, short- and long-term outcome at 2 years. Cathet Cardiovasc Interv 2009;74(2):225-31.
McKay RG, Safian RD, Berman AD, Diver DJ, Weinstein JS, Wyman RM, Cunningham MJ, McKay LL, Baim DS, Grossman W. Combined percutaneous aortic valvuloplasty and transluminal coronary angioplasty in adult patients with calcific aortic stenosis and coronary artery disease. Circulation 1987;76(6):1298-306.
Silber S, Albertsson P, Avilés FF, Camici PG, Colombo A, Hamm C, Jørgensen E, Marco J, Nordrehaug JE, Ruzyllo W, Urban P, Stone GW, Wijns W; Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology. Guidelines for percutaneous coronary interventions: the task force for percutaneous coronary interventions of the European Society of Cardiology. Eur Heart J 2005;26(8):804-47.
Dzavik V, Sleeper LA, Cocke TP, Moscucci M, Saucedo J, Hosat S, Jiang X, Slater J, LeJemtel T, Hochman JS; SHOCK Investigators. Early revascularization is associated with improved survival in elderly patients with acute myocardial infarction complicated by cardiogenic shock: a report from the SHOCK Trial Registry. Eur Heart J 2003;24(9):828-37.
Jacobs AK, French JK, Col J, Sleeper LA, Slater JN, Carnendran L, Boland J, Jiang X, LeJemtel T, Hochman JS. Cardiogenic shock with non-STsegment elevation myocardial infarction: a report from the SHOCK Trial Registry. SHould we emergently revascularize Occluded coronaries for Cardiogenic shocK? J Am Coll Cardiol 2000;36(3 Suppl A):1091-6.
Abbott JD, Hamed HN, Vlachos HA, Selzer F, Williams DO. Comparison of Outcome in Patients With STElevation Versus Non-ST-Elevation Acute Myocardial Infarction Treated With Percutaneous Coronary Intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry). Am J Cardiol 2007;100(2):190-5.
Come PC, Riley MF, Berman AD, Safian RD, Wakmonski CA, McKay RG. Serial assessment of mitral regurgitation by pulsed Doppler echocardiography in patients undergoing balloon aortic valvuloplasty. J Am Coll Cardiol 1989;14(3):677-82.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.