P090 - TRANS-CATHETER AORTIC VALVE IMPLANTATION IN A PATIENT WITH MEMBRANOUS VENTRICULAR SEPTAL DEFECT, SUB-AORTIC BAND AND DOUBLE-CHAMBERED RIGHT VENTRICLE: A CASE REPORT

Background: We report a rare case of trans-catheter aortic valve implantation (TAVI) in an elderly male with membranous ventricular septal defect (VSD), sub-aortic band, and severe aortic stenosis (AS). We discuss the safety and efficacy of the technique.

METHODS AND RESULTS: An 86-year-old male was admitted to our hospital with congestive heart failure. Trans-thoracic echocardiogram (TTE) identified low- flow low-gradient severe AS, a membranous ventricular septal defect (VSD). After treatment of CHF, we performed a trans-esophageal echocardiogram (TTE). A subaortic band was found in addition to severe AS and VSD. Cardiac CT identified a double chambered right ventricle. Coronary angiogram showed no significant stenosis. Right heart catheter showed Qp/Qs was 1.9 and pulmonary hypertension. Pressure gradient between high-pressure chamber and low-pressure chamber of right ventricle was 50mmHg. Main cause of CHF was considered as severe AS and VSD. Based on the guideline, surgical aortic valve replacement, VSD closure, subaortic band resection and myectomy of right ventricle would be considered as definitive treatment. The patient was not deemed to be a surgical candidate because of advanced age and frailty. Instead, we performed TAVI and VSD orifice closure using the skirt part of the self-expanding valve (26mm Evolut Pro PlusTM) because VSD occluder is not approved and thus not available in our country. The trans-catheter procedure resulted in a reduction of the mean aortic valve pressure gradient improved from 33 to 2 mmHg and a decrease in the shunt flow (Qp/Qs) from 1.9 to 1.2. Pulmonary hypertension improved although pressure gradient between high pressure chamber and low pressure chamber of right ventricle remained 50mmHg . The patient became asymptomatic after the procedure, and he was discharged home 7 days after the procedure. He remained well and had not been admitted to hospital since discharge.

Conclusion: TAVI using a valve skirt may be considered in a situation where a high-risk patient is inoperable and VSD closure devices are unavailable. To complete this procedure safely, meticulous pre-procedural evaluation including multiple imaging and accurate positioning using TEE are required. Discussions with specialists in imaging, adult congenital cardiology, cardiac surgery, anesthesiology and interventional cardiology are also important.