The aortic valve, which has the task of passing blood into the large artery which then distributes it to the body, was stenotic, that is, very narrow. And it had to be replaced. It is a pity, however, that the coronary arteries, both in the main component, the common trunk, and in its branches that supply specific parts of the heart, were heavily damaged by diffuse calcifications. In addition, the heart was a little “run down” in its function. In short, a really serious and complicated picture to deal with.
Yet two men of 78 and 79 years ago, a few months ago, solved a similar situation for both and so complex with a “combined” intervention. Ingredients: research, intuition and technology of the highest level with the use of different approaches able to favor the correction of the different aspects present.
The treatment was performed by the Heart Team of the Santa Maria di Bari Hospital, led by Alfredo Marchese, President of the Gise Foundation of the Italian Society of Interventional Cardiology. The cases, due to their characteristics of complexity and the pioneering approach used in the treatment, have been described in a publication that appeared on European Heart Journal.
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In fact, the two patients presented with severe aortic stenosis, with a narrowing of the aortic joint, and severe coronary disease of the common trunk and the main nearby vessels, not only narrowed but also with diffuse and severely calcific plaques. These conditions obviously increased the “operative” risk of Tavi (technique of replacing the aortic valve through a catheter that reaches the heart without resorting to surgery). Therefore they had to be resolved before proceeding with the replacement of the valve.
“Preliminary surgery to treat calcific coronary stenosis was necessary in order to proceed safely with the operation on the aortic valve – explains Marchese. This is because any complication during valve replacement would have been even more serious in the presence of untreated stenotic coronary arteries. However, the use of high pressure balloons or traditional ablation systems of calcified plaque would have increased the risk of coronary complications, even fatal, hence the use of the “shock wave” method to break the coronary calcified plaque with ultrasound. However, the operation becomes even more complex if, to this coronary picture, a serious impairment of the ventricular function (of the left ventricle or sometimes biventricular) is also associated. We therefore had to find the optimal therapeutic procedure that would lead to a concrete benefit for intervening on fragile patients with high procedural risk “.
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The Heart Team has therefore devised a multidisciplinary approach, combining procedures and technologies already used but never jointly so far: extracorporeal circulation system, what is defined as Ecmo, in combination with an aortic counter-pulsator to support the cardiovascular system, associating then coronary lithotripsy (shock wave treatment) to resolve calcifications and finally the procedure for replacing the aortic valve using Tavi.
The extracorporeal circulation made it possible to obtain the necessary support for the cardiovascular system and, to avoid possible side effects, an intra-aortic counter-pulsator was used in combination, a sort of balloon pump that supports the ventricular function, effectively reducing the workload of the heart and relieving him of the fatigue caused by coronary procedures. In this way the ventricle was able to work at its best.
Then, with the intravascular lithotripsyby exploiting the shock waves, we “worked” on calcification with controlled fractures, minimizing the destruction of the plaque and the risk of distal embolization (occlusion of peripheral blood vessels) and therefore of massive ischemia and severe left ventricular failure. Thanks to the treatment it was then easier to place a stent (mesh that protects the vessel in the narrowing area).
Finally, the aortic valve was replaced with the Tavi percutaneous technique resulting in faster recovery for patients compared to traditional surgery. “The minimally invasive approach used, the interventional cardiology procedures and the involvement of the Heart Team, not only in the decision-making phase but also in practice, have allowed us to carry out very complex interventions on often very elderly patients with comorbidities – concludes Marchese. This is an important step forward for those complex patients who often have complications or long-term stays and we have the opportunity to treat elderly people with comorbidities that would otherwise not be operable “.
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