Çoxqapaqlı patologiya və xronik böyrək çatışmazlığı olan xəstələrdə şiddətli aortal çatışmazlıqda TAVR seçim müdaxilə kimi

İlqar Tahiroglu; Şəhla Ağayeva; Ləman  Eyvazlı

doi:10.28942/acj.v26i2y2024.126

Abstrakt

Aort və mitral qapaq çatışmazlığının kombinasiyası çox rast gəlinən, lakin kifayət qədər öyrənilməmiş çoxlu qapaq xəstəliyinin tipik nümunəsidir. Transkateter aortal qapağın dəyişdirilməsi (TAVR) yüksək riskli Aortal Çatışmazlığı (AR) olan xəstələr üçün effektiv bir seçim ola bilər. Transkateter aort qapağı ilə əlaqəli potensial risklər arasında qapağın düzgün yerləşdirilməməsi səbəbindən yetərsiz möhürlənmə, qapağın embolizasiyası və əhəmiyyətli paravalvulyar çatışmazlıq yer alır. AR xəstələri adətən xəstəlik irəlilədikdə, sol mədəcik funksiyasının geri dönməz azalması və ağır pulmonar hipertoniya olduğu mərhələdə müdaxilə üçün göndərilir. Bu halda təqdim olunan xəstədə çoxlu qapaq patologiyası mövcuddur və eyni zamanda xroniki böyrək xəstəliyindən (CKD) əziyyət çəkir. Xəstəyə AVR cərrahiyyəsi tövsiyə olunmuşdur, lakin komorbid vəziyyət və yüksək əməliyyat riski (EUROSCORE – 11,17%) nəzərə alınaraq, ürək komandasının məsləhəti ilə TAVR tətbiq edilməsinə qərar verilmişdir.

Əsas mətn

Clinical Case: A 65 year old woman admitted to the hospital with worsening shortness of breath, weakness, dizziness. She had a long-standing history of hypertension and chronic kidney disease due to polycystic kidney disease (she has been receiving dialysis 3 times a week for 6 years).

Physical examination: There were single bibasilar crackles on lung auscultataion. Tricuspid insufficiency (TR-II). RV basal 42 mm, RV function (Tapse-27 mm, rvsm-16 sm/sec) is normal. MPA is dilated (35 mm), SPAP 50 mmHg. İVC is dilated (22 mm) and its collapse is reduced.

TEE: LVEF 40%, LV hypertrophy, global hypokinesis, longitudinal muscles contractility better than radial muscles. A decrease in GLS is noted due to eccentric severe aortic insufficiency in the posterior and inferior segments. Aortic valve leaflets are retracted, RCC is calcific, severe aortic regurgitation due to coaptation defect. Valve opening is limited and asymmetric, JET/LVOT- 0.9, vk-1.4 sm. Pulmonary artery is dilated and SPAP is increased. İAS is intact, there is a spontan left-to-right flow PFO.

Initial Diagnosis: Severe aortic insufficiency. Moderate Aortic stenosis. Heart failure NHYA class III. Pulmonary Hypertension type II. Hypertension class II. CKD.

Clinical course: The patient was hospitalized. The patient was treated for heart failure. Before the operation, a CT scan was performed and the coronary vessels were checked. Prepared for TAVI operation.

TAVI CT: RV basal-31 mm, LV basal-69 mm, RA-35 mm, LA-59 mm. Anulus diameter-30x23 mm, area-5.8 sm². Sinus Valsalva 32x32mm, area-8.5 sm². Sinotubular junction 32x33 mm, area-9.4 sm². CT angioqraphy: A long-segment eccentric calcific plaque causing 50-60% stenosis of the orifice in a 25-mm segment in the LAD-mid. Calcific plaque causing moderate orifice stenosis in a 13-mm segment of the LAD Diagonal branch. Cx-open, RCA-dominant, open.

Pre-op Analysis: WBC 6.56 10³ u/L, HGB 12.5 q/dl, HCT 37.5 %, PLT 243 10³/uL, NEUT 4.32 10³/uL, LYMPH 1.42 10³/uL, AST 35.8 U/L, ALT 34.2 U/L, Serum Creatinine 4.31 mg/dl, CRP 4.72 mg/l, Potassium 4.76 MMOL/L, PT- 10.6 san, İNR 1.01.

Treatment: Sefamezin 1.0 mg x2, Finerone 10mg x1, Clopidogrel 75 mg x1, Atorvastatine 40 mg x1, Clexane 0,4 mg x1, Lasix 20 mg x1, Pantap 40 mg x1 was started.

TAVI Procedure: Femoral sheaths were placed into right femoral artery, left femoral artery and vein. A temporary pacemaker was implanted via left femoral vein. A pigtail catheter was placed in the noncoronary cusp, and a stiff Confida wire was placed inside the left ventricle. The 34 mm Medtronic Evolute PRO+ Valve was carefully advanced until the aortic annulus, positioned and deployed under rapid ventricular pacing. After deployment, rapid ventricular pacing stimulation was kept. Any hemodynamically significant leakage and gradient were not observed in valve. During intraop TEE, no residual AR was observed and decrease in mitral regurgitation severity was noted immediately after procedure. The patient was admitted to the intensive care unit. Dialysis was performed, 1200 ml of fluid was withdrawn during dialysis. During the patient's rehabilitation period, control analyzes were reviewed-06.09.2024. Hgb-10.8 q/dl, HCT -32.8, Serum Creatinine- 6.20 mg/dl, CRP- 16.82 mg/l.

Post-op ECG: Sinus rhythm, HR 77 bpm, single atrial extrasystoles. On post-op ECG single atrial extrasystoles are seen, and given the patient’s complaints of palpitations, Concor 2.5 mg x1 was added. Medical treatment was corrected.

Post-op Echocardiography: LVEF- 45%, MR-II, TR-I-II, SPAP- 30 mmHg. During follow-up, the patient had considerable clinical improvement, with better quality of life and NHYA II.

Discussion points:

CKD and HF: CKD is generally associated with an increase risk of mortality, cardiovascular events and readmission for heart failure; this supports the concept of a cardio-renal syndrome (CRS). Our patient has end-stage renal disease with GFR 11 mL/min and dialysis require but with minimal daily free diuresis along with CRS type II clinic. CRS type II (chronic cardio-renal syndrome) portray venous congestion along with considerable reductions in cardiac output as a result of cardiac dysfunction, leading to a reduction in the glomerular filtration rate (GFR). Studies have additionally disclosed that angiotensin II has a direct effect on renal tubular cells and cardiomyocytes and is also known to promote fibrosis, cellular hypertrophy, and apoptosis.

AR and pulmonary hypertension: In patients with aortic and/or mitral valve disease the presence of pulmonary hypertension (PH) indicates a decompensated state of the disease with left ventricular and left atrial dysfunction and exhausted compensatory mechanism, i.e., a state of heart failure. In patients with ≥moderate AR, PHT is associated with a progressive risk of mortality, even at mildly elevated levels.

AR and multivalve pathology: Chronic kidney disease (CKD) is a major risk factor for valvular heart disease (VHD). Varying degrees of MR may result from remodelling, shape distortion and impaired function of the left ventricle (LV) associated with severe AR, thereby restricting mitral valve motion. Both AR and MR increase left ventricular (LV) preload, whereas only AR has a significant effect on afterload, as a result of the impact of the increased total stroke volume ejected on systemic vascular resistance, and of the resulting systolic hypertension. Valvular heart calcification is common in patients with chronic kidney disease (CKD), especially in those receiving hemodialysis therapy, and it is associated with poor prognosis. Premature AVC and MAC is frequent in dialysis patients, which commonly lead to valvular stenosis and regurgitation and appears to be related to abnormal calcium and phosphate metabolism and to increased mechanical stress on the valve cusps. In a small but important group of patients on long-term dialysis, premature valve calcification is severe and produces aortic stenosis, or less frequently, mitral stenosis. VHD, especially mitral regurgitation and aortic stenosis, is associated with significantly reduced survival among CKD patients. Progressive sclerosis and calcification of the valves and valvular annuli are major components of the etiology. CKD is also associated with left ventricular remodelling and dysfunction, which might contribute to increase the risk of heart failure and death in patients with VHD. One concomitant valve lesion can modify the clinical effect of another. In our clinical case, with the resolution of aortic regurgitation by TAVI, we see a decrease in the level of mitral regurgitation and a decrease in the patient's complaints.

Conclusion: TAVR is a promising option in AR. Our patient has Stage 3 (tricuspid valve or pulmonary artery vasculature damage) cardiac damage. This patient had a high surgical risk and poor prognosis if any intervention wouldn’t performed. In our clinical case, taking into account that the patient had end-stage renal disease, we decided that primary aortic valve insufficiency appeared, then other valvular pathologies appeared on the background of AR, and after AR was resolved by transaortic valve replacement, we observed an improvement in other valvular pathologies severity and the patient's clinical condition.

Cardiac: A crescendo-decrescendo mid systolic murmur was heard along the right 2nd intercostal space and radiated to the neck.

Vital signs: BP- 140/80 mmHg, HR 88 bpm, body temperature -36.6°C, RR -18 bpm, SpO2-98%

ECG: Sinus rhythm, HR 76 bpm, in I, AVL, V4-V6 leads minimal ST depression.

Pre-op Echocardiography: LVEF-40%, LV spheric remodeled, biatrial dilation and elongation (LA 58x70, RA 39x59), AS gradient 36/22mmHg, severe aortic insufficiency (AR-severe, PHT -196 msec, jet/LVOT-0.9, a holodiastolic reverse flow in descending aorta was noted. Severe mitral insufficiency (MR-III). Moderate.