Transcatheter aortic valve replacement performed via left ventricular assist device inflow cannula.

A 62-year-old woman with a history of lung cancer, prior surgical aortic valve replacement with a 23-mm Hancock (Medtronic, Inc, Minneapolis, MN) porcine valve, and non-ischemic cardiomyopathy supported with a HeartMate II destination therapy left ventricular assist device (LVAD; Thoratec Corporation, Pleasanton, CA) presented with hemolytic anemia (hemoglobin, 6.8 g/dL; lactate dehydrogenase, 1536 U/L) because of LVAD thrombosis and severe insufficiency of the 23-mm Hancock bioprosthetic valve (Figure 1; Movie I in the Data Supplement). Given her comorbidities and multiple prior sternotomies, she was felt to be a poor candidate for combined redo-surgical aortic valve and LVAD replacement via another sternotomy. Peripheral vascular disease precluded transfemo-ral transcatheter aortic valve replacement (TAVR). Therefore, it was decided that she would be best treated with concomitant LVAD pump exchange and TAVR via a transapical approach using the existing LVAD inflow cannula for access. A 5-cm incision was made below the lateral two thirds of the right clavicle to access the right axillary artery, and a 6-mm Dacron graft anastomosed to the axillary artery in an end-to-side manner to be used for cardiopulmonary bypass inflow with the side graft technique. A second incision inferior to the breast through the left fifth intercostal space was then performed and dissection carried down to the level of the fifth rib. The pleural space was opened, and a segment of fifth rib excised to allow better access to the LVAD inflow cannula. The outer silastic covering of the apical inflow cannula was removed to expose the Dacron inflow graft of the Heartmate II LVAD. Percutaneous right femoral venous access was obtained, and a 25F Bio-Medicus multistage venous cannula (Medtronic, Inc, Minneapolis, MN) advanced into the right atrium/proxi-mal superior vena cava junction under fluoroscopic guidance. The outflow graft of the LVAD was unscrewed from the pump and then occluded with a 30-mm Coda balloon catheter (Cook Medical, Bloomington, IN; Figure 1). The Dacron inflow graft of the LVAD was divided and clamped and the LVAD pump removed. Because of the short length of the inflow graft, a 12-mm knitted Dacron graft was anastomosed end-to-end to the inflow graft to provide additional working length in which to place a 26F transcatheter heart valve delivery sheath (Figure 2). Use of this Dacron graft extension allowed the graft to be punctured on its anterior surface and serially dilated for large bore sheath placement with minimal blood loss, essentially identical to the standard …