Transapical Placement of an Uncovered Aortic Endostent for Type A Aortic Dissection

We report on transapical implantation of an uncovered aortic endostent for treatment of iatrogenic acute type A aortic dissection.A 91-year-old female patient presented with recent onset of increasing shortness of breath and fatigue and temporary disorientation caused by severe aortic valve stenosis (Figure 1 and online-only Data Supplement Videos 1 and 2). Her medical history included cachexia (body mass index, 17.9 kg/m2; body surface area, 1.39 m2), severe spondylosis, osteochondrosis, and osteoporotic vertebral body fracture. Transcatheter aortic valve implantation (TAVI) was favored because of her frailty, poor general condition and increased risk for conventional surgery (logistic EuroSCORE, 29%; STS score, 13%). The transapical approach for TAVI was chosen because of tortuosity and atherosclerotic disease of the small iliaco-femoral arteries. The procedure was monitored by fluoroscopy, angiography, and continuous transesophageal echocardiography (TEE). After implantation of a 23-mm Edwards-Sapien valve (Edwards-Sapien THV, Edwards Lifesciences, Irvine, CA), TEE and angiography showed a new finding of dissection of the whole aorta and also excluded possible intimal tear (“entry”) in the proximal or mid ascending aorta (Figures 2 and 3 and online-only Data Supplement Videos 3–6). We closed the false lumen in the ascending aorta and aortic arch by immediate transapical implantation of an uncovered aortic endostent into the ascending aorta and aortic arch. We chose the uncovered aortic self-expandable aortic E-xl endostent …