Use of Patient-Specific 3-Dimensional Printed Models for Planning a Valve-in-Valve Transcatheter Aortic Valve Replacement and Educating Health Personnel, Patients, and Families

摘要

Background: Aortic stenosis is a common disease of the elderly. Valve replacement with open surgery is the preferred therapy for many patients with low surgical risk. Bioprosthetic valve failure occurs in up to 66% of patients and has a worse prognosis when the mechanism of failure is stenosis compared to regurgitation.Case Report: An 80-year-old female with a medical history of surgical aortic valve replacement, diabetes, chronic back pain, coronary artery disease, and hypertension was referred to the interventional cardiology clinic for heart failure symptoms. A bioprosthetic valve placement that was small for the patient's size (effective orifice area/body surface area 0.75 cm~(2)/m~(2)) resulted in symptomatic improvement that lasted for 7 years. The patient underwent an aortic valve-in-valve transcatheter valve replacement with excellent outcomes. Preoperative planning involved a patient-specific 3-dimensional printed patient model.Conclusion: In patients at high surgical risk, transcatheter aortic valve replacement is a fundamental pillar of treatment. However, valve-in-valve procedures have specific anatomic challenges, such as the risk of coronary artery obstruction and the limitation of valve expansion inside a rigid bioprosthetic valve frame. In those difficult cases, interventional cardiologists must make precise decisions regarding the approach. Three-dimensional models can be printed with the patient's specific measurements. This approach represents truly personalized medicine and can serve as a tool for procedural planning, education of the health personnel involved in the case, and patient and family engagement. Keywords: Aortic valve stenosis , imaging–three-dimensional , transcatheter aortic valve replacement INTRODUCTIONPatient-specific 3-dimensional (3-D) printed models for structural heart disease have been demonstrated to be useful tools in interventional cardiology.~(1,2) These models have been used to improve outcomes in technically challenging cases, allowing for planning, education of the health team, and patient and family engagement. With the use of 3-D models, the heart team can visualize the patient's anatomy and any associated clinical problems and can provide the patient and family with a clear image of what is happening inside the heart and how the condition is going to be treated.~(1,2)Aortic stenosis is a common disease of the elderly; prevalence increases after 65 years of age, and after age 80 years, 1 of 3 people will have severe aortic stenosis.~(3) Surgical aortic valve replacement (SAVR) is a common treatment for severe aortic stenosis, but it is associated with the risk of patient-prosthesis mismatch (PPM), and the prevalence of severe PPM (effective orifice area [EOA]/body surface area [BSA] <0.65 cm~(2)/m~(2)) is 2% to 10%.~(4) Bioprosthetic valve failure occurs in up to 66% of patients~(5) and has a worse prognosis when the mechanism of failure is stenosis rather than regurgitation.~(6) PPM provides a partial explanation for this observation and is a problem especially in patients with small aortic roots who undergo SAVR. PPM occurs when the EOA of the implanted prosthetic valve is small related to the BSA. Patients with stenotic physiology who have bioprosthetic valve failure tend to have a combination of PPM and decreased leaflet mobility of the bioprosthetic valve. Walther et al showed a lower 5-year survival rate in patients with severe PPM vs patients without PPM (76.8% vs 81%) in an analysis of 4,131 patients.~(7) They also showed that an EOA/BSA <0.85 cm~(2)/m~(2) was a significant risk factor for adverse cardiac events. Treatment options for PPM include reoperation~(8) and valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). Reoperation is associated with significant perioperative complications, including respiratory failure, reoperation for bleeding, acute myocardial infarction, need for intraaortic balloon pump, renal failure, sepsis or endocarditis, stroke, and gastrointestinal complications.~(3,8) Redo SAVR is a technically demanding procedure because of the scarred surgical field; the risk of iatrogenic injury to cardiovascular structures; and the higher risk of bleeding, transfusions, and transfusion-related morbidity compared to the first-time operation.~(8) ViV TAVR is a reasonable alternative but also has specific technical challenges. The rigidity of the bioprosthetic ring limits the size of the valve that can be used, further contributing to the PPM problem and causing a Russian doll–type effect (ie, the need to place a smaller prothesis every time to fit inside the preexisting one). This problem can be overcome by bioprosthetic valve fracture with high-pressure noncompliant balloon inflations; however, not all bioprostheses are susceptible to being fractured. Another challenge is that the risk of coronary artery occlusion is significantly higher with ViV procedures compared to TAVR in native aortic valves. The anatomic interacti