Matthias Kirsch

Background Despite the gold-standard approach for transaortic valve implantation (TAVI) remains transfemoral (TF), alternative approaches are needed in patients who present contraindications to transfemoral access. Case summary We report the case of a 79-year-old female with a symptomatic high-gradient severe aortic stenosis—mean gradient of 43 mmHg—and a significant supra-aortic trunk stenosis (left carotid artery: 90–99%; right carotid artery: 50–70%), and who was hospitalized for progressive dyspnoea New York Heart Association (NYHA) stage III. In this high-risk patient, it was decided to perform a TAVI. Because of a history of stenting of both common iliac arteries in a context of an arterial insufficiency of the lower limbs (Leriche classification stage III) and stenotic thoraco-abdominal aorta atheromatosis, an alternative approach to the transfemoral transaortic valve implantation (TF-TAVI) one was needed. It was decided to perform a combined transcarotid-TAVI (TC-TAVI) with EDWARDS S3 23 mm valve with a left endarteriectomy during the same operating time. Discussion Our case illustrates an alternative approach to perform a percutaneous aortic valve implantation, despite supra-aortic trunk stenosis, in a high-risk surgical patient contraindicated to a TF-TAVI. Transcarotid transaortic valve implantation remains a safe alternative when TF-TAVI is contraindicated, and the combined approach of carotid endarteriectomy and TC-TAVI offers a minimally invasive one-step treatment in high operative risk patients.

Antibody‐mediated rejection (AMR) is a major barrier preventing successful discordant organ xenotransplantation, but it also occurs in allotransplantation due to anti‐HLA antibodies. Symptomatic acute AMR is rare after heart allograft but carries a high risk of mortality, especially >1 year after transplant. As complement activation may play a major role in mediating tissue injury in acute AMR, drugs blocking the terminal complement cascade like eculizumab may be useful, particularly since “standards of care” like plasmapheresis are not based on strong evidence. Eculizumab was successfully used to treat early acute kidney AMR, a typical condition of “active AMR,” but showed mitigated results in late AMR, where “chronic active” lesions are more prevalent. Here, we report the case of a heart recipient who presented with acute heart failure due to late acute AMR with eight de novo donor‐specific anti‐HLA antibodies (DSA), and who fully recovered allograft function and completely cleared DSA following plasmapheresis‐free upfront eculizumab administration in addition to thymoglobulin, intravenous immunoglobulins (IVIG), and rituximab. Several clinical (acute onset, abrupt and severe loss of graft function), biological (sudden high‐level production of DSA), and pathological features (microvascular injury, C4d deposits) of this cardiac recipient are shared with early kidney AMR and may indicate a strong role of complement in the pathogenesis of acute graft injury that may respond to drugs like eculizumab. Terminal complement blockade should be further explored to treat acute AMR in recipients of heart allografts and possibly also in recipients of discordant xenografts in the future.