Advances In Valve Treatment

Complex Case: Aortic Valve Replacement Combined
 with AAA Repair

The patient was an 84-year-old man, a former smoker with a long history of coronary disease, who had prior coronary stents and a three-vessel coronary artery bypass graft surgery.

He also had chronic atrial fibrillation. In addition, he had calcific aortic stenosis. In summer 2013, when the patient saw his local cardiologist, he was in Class III heart failure with severe shortness of breath, and was found to have severe aortic stenosis. During a computer tomography (CT) scan of the kidney for a suspected tumor, he was found to have a 7 cm abdominal aortic aneurysm, well beyond the 5 cm at which intervention is recommended, with a chance of rupture as high as 30–40 percent. The severe aortic stenosis with decompensating heart failure was thought to need prompt intervention for fear of further decompensation, and the large abdominal aneurysm placed him at risk for rupture and sudden death.

The local cardiologist referred the patient to an academic medical center in New York City, where he was evaluated. Initial evaluation there determined that the patient’s native valve was too large for a transcatheter aortic valve replace­ment (TAVR) procedure. The physicians there recommended three separate sequential  procedures: an initial balloon valvuloplasty; followed by aneurysm repair; and then a subsequent open preoperative aortic valve replacement. The patient’s cardiologist was concerned about whether his patient could survive this series of procedures and sought another opinion. He referred the patient to NYU Langone Medical Center, where he was jointly evaluated by Aubrey C. Galloway, MD, the Seymour Cohn Professor of Cardiothoracic Surgery and chair of the Department of Cardiothoracic Surgery, and Mark A. Adelman, MD, the Frank J. Veith, MD Professor of Vascular and Endovascular Surgery and chief of the Division of Vascular Surgery. After conferring, the two surgeons agreed that sequential procedures and surgeries would pose potential significant risks. After the valvuloplasty, if the heart valve surgery was done first, there was risk of significant coagulopathy and bleed secondary to lytic components from the large clot in the aneurysm, plus a risk of aneurysm rupture. If the aneurysm repair were performed first, the heart might not be able to deliver adequate cardiac output to the patient during surgery, and he might decompensate and not survive.

Dr. Galloway and Dr. Adelman agreed that the patient was a strong candidate for a simultaneous combined operation: Dr. Adelman would perform an endovascular AAA procedure and Dr. Galloway would perform a minimally invasive aortic valve replacement procedure. The combined operation — ​which would eliminate the need for a balloon valvuloplasty and sequential surgical procedure — ​was to be performed in NYU Langone’s hybrid operating room (OR). Dr. Galloway and Dr. Adelman collaborated on the strategy for the surgery, starting with sequencing the procedures. After weighing the risks, they determined that the safest sequence was for endovascular AAA repair to be per­formed first, followed immediately by minimally invasive aortic valve replacement.

On August 27, 2013, in a 2-hour procedure, Dr. Adelman performed an endovascular repair of the aneurysm through two small incisions in each groin to insert a stent graft. When this procedure was complete, Dr. Galloway joined Dr. Adelman in the hybrid OR, where they worked side by side. A mini-sternotomy incision was performed, the patient was placed on the heart-lung machine and Dr. Galloway replaced the aortic valve in a 2.5-hour procedure.

During the operation, highly sophisticated computer software in the hybrid OR allowed Dr. Adelman to see three-dimensional images of the patient’s aorta. A diagnostic CT scan acquired before the operation provided high-resolution images of the vascular system. Through complex imaging, the stored images of the aorta were placed as an overlay to the live patient. This technique allowed Dr. Adelman to minimize contrast injection and radiation exposure during the surgery.

Following the surgery, the patient was out of heart failure, and risk of rupture of the aneurysm was removed. He had good perioperative recovery and was discharged from the hospital in under one week. By offering a combined case, NYU  Langone’s cardiac and vascular surgery teams limited the exposure and risk of separate sequential procedures for the patient, allowing for one anesthetic time for this 84-year-old patient. The patient no longer has aortic stenosis or a life-threatening aneurysm. This hybrid operation — ​the first of its kind at NYU Langone — ​eliminated multiple risks for the patient and shortened his hospital time to a week, virtually the same recovery time that is usual for minimally invasive aortic valve replacement alone in a patient this age. By avoiding full sternotomy, the recovery time for return to full function for this patient was significantly shortened, with faster healing and with less pain than if he had had open heart surgery and multiple procedures.

During every phase of care and continuing several months post discharge, the surgeons maintained close communication with the patient’s local cardiologist. The patient saw the surgeons for follow-up visits once a week for the first month after the surgery, and then bimonthly after that. The patient is doing well and has an excellent prognosis.