Transcatheter aortic valve replacement via a transsubclavian approach in a patient with severe aortic stenosis who had previously undergone kidney transplantation

Rationale: Although the transfemoral approach is the gold standard for transcatheter aortic valve replacement (TAVR), it is not feasible in a considerable number of patients. We report a case of successful transsubclavian TAVR (TS-TAVR) in a patient with severe aortic stenosis (AS) who was ineligible for transfemoral TAVR because she was a kidney transplant recipient. Patient concerns: A 72-year-old Korean woman, who had previously undergone kidney transplantation in the right iliac fossa for end-stage kidney disease, was admitted to our center with dyspnea. Upon auscultation, grade IV systolic murmurs were detected in both upper sternal borders and the left lower sternal border, suggestive of valvular heart disease. Diagnosis: Two-dimensional transthoracic echocardiography revealed heavy calcification of the aortic valve with a high peak velocity (4.54 m/s) and mean pressure gradient (48.49 mm Hg), indicative of severe AS. Interventions: TS-TAVR was performed by a heart team comprised of interventional cardiologists, cardiac surgeons, and anesthesiologists. A self-expandable valve prosthesis (CoreValve TM Evolut R TM , Medtronic Inc., Minneapolis, MN) was successfully deployed via the left subclavian artery. Outcomes: Post-TAVR 2-dimensional transthoracic echocardiography demonstrated a well-functioning valve with mild paravalvular leakage. The peak velocity had declined from 4.54 m/s to 2.22 to 2.24 m/s, and the mean pressure gradient had declined from 48.49 to 8.57–9.61 mmHg. The patient was discharged successfully and uneventfully. Lessons: Because kidney transplant recipients with severe AS are considered poor candidates for transfemoral TAVR, TS-TAVR is a suitable alternative to consider.