Cardiologists from the Hackensack University Medical Center (Hackensack, NJ, USA) have reported what is believed to be the very first patient with heart failure and a blood clot to undergo a minimally invasive transcatheter aortic valve replacement using CT (computed tomography) fusion imaging, a technique that employs two different imaging modalities.

The patient was a 78-year-old man with a history of obesity, high blood pressure, and coronary artery disease. He came to the hospital with worsening labored breathing on exertion and swelling in the lower extremities over three months. His imaging workup revealed severe stenosis of the aortic valve, left ventricular (LV) ejection fraction of 45% to 50%, and LV apical aneurysm with thrombus (an outpouching of the left ventricle with a blood clot). Ejection fraction is a measurement of the percentage of blood leaving the heart each time it contracts.

Cardiac catheterization showed severe coronary artery disease that was not amenable to minimally invasive procedures used to open clogged coronary arteries. He was started on anticoagulation with warfarin with planned follow-up. The patient returned to the hospital six months later due to loss of consciousness from low blood pressure. Four-dimensional volume-rendered computed tomography (CT) images showed persistent left ventricle apical thrombus. The Heart & Vascular Hospital team elected to proceed with transcatheter aortic valve replacement (TAVR) given his high surgical risk, poor functional status, lack of response to anticoagulation, and hospitalization for fainting. Because of the risk posed by the apical thrombus, TAVR with CT fusion imaging (CTFI) guidance and cerebral embolic protection was planned. The patient had an uneventful hospital course; there was no evidence of cerebral or systemic embolization. He was discharged in a few days and was doing well at his one month follow up appointment.

“We believe this case is potentially groundbreaking because of its successful outcome and the fact that the presence of left-ventricle thrombus or blood clot has historically been considered to be a contraindication to transcatheter aortic valve replacement, an alternative to open-heart surgery to replace heart valves in patients with heart disease,” said Rahul Vasudev, M.D. “Although the nature of catheter manipulation in the left ventricle during the procedure cannot guarantee absence of contact with the blood clot, advances in imaging technology and embolic protection may allow transcatheter aortic valve replacement, if a surgical alternative is not possible, to be performed with greater safety in this setting.”

“We believe this was the first case of TAVR with real-time CTFI to facilitate wire and catheter positioning to avoid disruption of the left ventricle thrombus,” said Tilak K. R. Pasala, interim director, Structural and Congenital Heart Disease Program.

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