P302 simultaneous correction of severe low–flow low–gradient aortic stenosis and abdominal aortic aneurysm by tavi + evar

Abstract We report the case of a 72–year–old man with arterial hypertension, dyslipidemia, type 2 diabetes mellitus, and severe chronic obstructive pulmonary disease. The patient had a previous stroke with occlusion of both internal carotid arteries about 7 years ago. He presented to the emergency department with dyspnea on exertion (NYHA class III), and the echocardiogram revealed a dilated left ventricle with severe reduction of global systolic function (EF 35%), severe low–flow low–gradient aortic stenosis (AVA on VTI 0.526 cmq/mq, SVi 29.7 ml/mq, Gmax 25.6 mmHg, Gmed 16 mmHg), and abdominal aortic aneurysm. Subsequently, he underwent an angio–CT scan that showed an almost completely thrombosed abdominal aortic aneurysm with a maximum diameter of 65 mm and a longitudinal extension of about 11 cm. The patient also underwent coronary angiography, which showed diffuse calcified atherosclerosis, and he was recommended for medical therapy. After a joint Heart Team consultation with cardio–anesthesiologists, cardiac surgeons, and vascular surgeons, it was decided to perform transfemoral transcatheter aortic valve implantation (TAVI) and endovascular aneurysm repair (EVAR) in the same procedure (EUROSCORE II > 4%). The patient underwent TAVI followed by EVAR of the aorto–bisiliac arteries through a main access site in the left femoral artery guided by ultrasound, a secondary access site in the right femoral artery for placement of a pigtail catheter on the aortic plane, and a venous access site in the right femoral vein for placement of a temporary pacing catheter at the apex of the right ventricle. First, an Edwards Sapien 3 Ultra 26mm valve was implanted, and then the 14Fr sheath in the left femoral artery was exchanged for an 18Fr sheath for the EVAR, which was placed in the aorto–bisiliac region. Hemostasis was achieved using the Manta system on the left femoral artery and two Proglide devices on the right femoral artery. The procedure was completed without complications, and the patient was discharged 10 days later, asymptomatic and in stable clinical condition, with a recommendation for dual antiplatelet therapy with aspirin and clopidogrel. At the 6–week follow–up, the patient remained asymptomatic with an EF of 40%. Conclusion In selected cases, the simultaneous correction of severe low–flow low–gradient aortic stenosis using TAVI and abdominal aortic aneurysm using EVAR can be considered after appropriate discussion and consultation within the Heart Team."