Transcatheter aortic valve implantation (TAVI) with zero contrast in patients with impairment of renal function. A single centre experience

Abstract   Transcatheter aortic valve implantation (TAVI) represents nowaday a safe and effective alternative to traditional surgery for patients with high and intermediate surgical risk. However, the risk of contrast induced nephropathy still remains a major concern and a real challenge in patients with baseline chronic kidney disease (CKD). Aim of our new approach, has been to find a solution capable to reduce or contain the incidence of acute renal damage after TAVI caused by the use of contrast dye in CKD patients. In the last twelve months, out of 85 patients admitted to our Center for severe symptomatic aortic stenosis, addressed to TAVI, 18 patients (mean age: 81.8 years, NYHA class III) presented CKD with mean creatinine value: 2.39 mg/dl; GFR: 24.46 ml/min/1.73 m2. Three patients had previously undergone surgical revascularization with coronary artery bypass graft and in 3 cases we performed a valve-in-valve procedure for degeneration of valvular bioprostheses.They were selected for our zero contrast protocol; all these patients underwent pre-procedural chest and abdomen CT scan without dye, together with a Lower Limb Eco-Color Doppler scan.Coronary angiography had been carried out in a previous hospitalization. The valve size choice was determined after measurements of the CT scan and echo images (both two- and three-dimensions) were compared. Data obtained (valve perimeter, area and the two main valve diameters) were strongly similar with the two techniques, without significant differences. The new valve deployment was monitored under constant fluoroscopy and transesophageal (TOE) visualization. A single pig tail catheter was placed in the non coronary sinus to facilitate valve annulus localization on fluoroscopy. The TOE selected view for TAVI deployment was the mid esophageal long axis. Proper prosthesis positioning was determined by measuring the protruding portion through the left ventricle outflow tract, and prevent possible impairment of diastolic mitral valve movement. In 17 cases a transfemoral percutaneous approach was used and only in one case surgical isolation of the right carotid artery was necessary due to the occlusion of every other peripheral access. Four patients needed a post implant dilatation for significant residual left ventricle/aortic gradient. All patients underwent the TAVI procedure successfully. In the post-TAVI phase, two patients underwent definitive PM implantation for third degree atrioventricular block despite adequately high implantation of the valve.At discharge, mean creatinine value was 1.9 mg/dl and mean GFR was 32.2 ml/min/1.73 m2. All patients survived the procedure and were discharged alive, after a further mean Hospital stay of four days. In conclusion, TAVI zero contrast is a safe, feasible and winning procedure to consider in patients with severely impaired renal function. Funding Acknowledgement Type of funding sources: None.