Reversible thrombotic aortic valve restenosis after valve‐in‐valve transcatheter aortic valve replacement

Thrombotic aortic valve restenosis following transcatheter aortic valve replacement (TAVR) has not been extensively reported and the rates of TAVR valve thrombosis are not known. We present three cases of valve‐in‐valve (VIV) restenosis following TAVR with the balloon expandable transcatheter heart valves, presumably due to valve thrombosis that improved with anticoagulation. © 2016 Wiley Periodicals, Inc.     

Transcatheter aortic valve implantation for treatment of patients with degenerated aortic bioprostheses—valve‐in‐valve technique

Background: The management of patients with degeneration of surgical bioprosthetic valve replacement remains a challenge because of the higher risk of re‐do aortic valve replacement. We present a case series of five patients with degenerated aortic bioprostheses treated with transfemoral transcatheter aortic valve implantation (TAVI). Methods: From December 2009 to May 2010, five patients with degenerated aortic valve bioprostheses (aortic valve area < 1 cm² or severe aortic regurgitation), an excessive operative risk (EuroSCORE ≥ 30%), symptoms of heart failure (NYHA ≥ III) and an internal diameter of bioprosthetic aortic valve 20.5 ± 0.5 mm were included. Procedures were performed without hemodynamic support using femoral arteries. Balloon valvuloplasty with a 20‐mm balloon under rapid pacing was carried out before valve implantation. The 26‐mm CoreValve prosthesis, 18‐F‐generation (Medtronic, Minneapolis, Minnesota) was inserted retrograde under fluoroscopic guidance. Invasive and echocardiographic measurements were done immediately before and after TAVI. Clinical followup and echocardiography were performed after procedure (mean followup 72 days ± 60, range: 176–30 days). Results: In all patients TAVI was successful with immediate decrease of transaortic peak‐to‐peak pressure (P = 0.002). Mild aortic regurgitation occurred in two patients and one patient received a new permanent pacemaker. Major adverse cardiac and cerebrovascular events did not arise. NYHA functional class improved in all patients and left ventricular ejection fraction increased (P = 0.019). Conclusion: Our experiences with the valve‐in‐valve technique using the CoreValve prosthesis suggest that transfemoral TAVI is feasible in high risk patients with degenerated aortic bioprostheses. © 2010 Wiley‐Liss, Inc.     

Transcatheter aortic valve implantation 10 years after valve‐in‐valve transcatheter aortic valve implantation for failing aortic valve homograft root replacement

Valve‐in‐valve transcatheter aortic valve implantation (ViV‐TAVI) is an established therapy for a degenerated surgical bioprosthesis. TAVI‐in‐TAVI following ViV‐TAVI has not been previously performed. We report a high‐risk patient presenting with severe left ventricular failure secondary to undiagnosed critical aortic stenosis due to degeneration of the implanted transcatheter heart valve more than a decade after initial ViV‐TAVI for a failing stentless aortic valve homograft. Successful TAVI‐in‐TAVI reversed the clinical and echocardiographic changes of decompensated heart failure with no evidence of coronary obstruction.     

Sequential trans‐catheter aortic valve implantation and abdominal aortic aneurysm repair

Aortic stenosis in the elderly population is an increasing problem, with many patients being considered too high risk for surgery, and therefore being denied treatment. A percutaneous method of treatment in the form of trans‐catheter aortic valve implantation (TAVI) is becoming an increasingly attractive option in this group of patients. Although, TAVI has been shown to be successful and improve cardiovascular haemodynamics, assessment of other comorbidities in this susceptible group of patients is essential to ensure good clinical outcomes. The presence of an abdominal aortic aneurysm (AAA) in our patient was an example of an important comorbidity which could have a significant impact on the outcome of TAVI, if not managed appropriately. The increased systolic pressure post successful TAVI will result in an increased strain within the AAA with an increased risk of rupture. Therefore, a timely management strategy for the AAA was necessary. Our case is of sequential TAVI followed by Endovascular aneurysm repair (EVAR). The patient underwent uncomplicated TAVI. There was complete abolition of trans‐aortic gradient. EVAR was successfully undertaken three weeks post TAVI. The patient made an excellent recovery and remained well at six months follow‐up. Our case highlights the importance of a detailed assessment in all patients prior to consideration for TAVI and the importance of having a management strategy for both pathologies tailored to the patient. This case demonstrates the benefits of development of trans‐catheter techniques for two different conditions. Future developments including reduction of sheath size reduction and EVAR and TAVI device evolution, may enable simultaneous treatment of aortic stenosis and abdominal aortic aneurysm as a combined percutaneous procedure under local anaesthetic. © 2011 Wiley Periodicals, Inc.     

Procedural and clinical outcomes of the valve‐in‐valve technique for severe aortic insufficiency after balloon‐expandable transcatheter aortic valve replacement

Objective : To describe the clinical and procedural outcomes of patients treated with the valve‐in‐valve technique for severe aortic insufficiency (AI) after balloon‐expandable transcatheter aortic valve replacement (TAVR). Background : Severe AI immediately after valve implantation is a notable complication of TAVR. It can be treated with a valve‐in‐valve technique which involves deploying a second valve within the first one to crush the leaflets of the first implant leaving a new functional valve. Methods : We analyzed data on 142 consecutive patients at our institution undergoing TAVR with the Sapien valve between November of 2007 and April of 2011. Etiologies of acute AI, procedural and intermediate term clinical outcomes were reported for those in whom a valve‐in‐valve procedure was necessary. Post‐hoc analysis of these cases with C‐THV imaging (Paieon Medical Ltd.) was performed to elucidate the mechanism for successful AI treatment. Results : A total of 5 of 142 (3.5%) patients were treated with the valve‐in‐valve technique. Etiologies of the aortic valve insufficiency included bioprosthesis malposition (n = 3), valve dysfunction (n = 1), and valve undersizing (n = 1). With placement of the second valve, the first valve dimensions increased to approach the nominal valve size while the second valve size remained less than nominal. Conclusions : The valve‐in‐valve technique is an appropriate bailout measure for patients with acute valvular AI after balloon‐expandable TAVR. © 2012 Wiley Periodicals Inc.     

First percutaneous transcatheter aortic valve‐in‐valve implant with three year follow‐up

Objectives: This study was conducted to report the clinical, hemodynamic, and iconographic outcomes of the longest survivor of the global CoreValve experience. Background: Early results of percutaneous heart valve (PHV) implantation for severe symptomatic aortic stenosis (AS) have been encouraging, with mid term survival up to 2 years; however longer durability term is unknown. Although a PHV has been implanted in a degenerated surgical bioprosthesis, the feasibility of a PHV‐in‐PHV has not been demonstrated. Methods: A patient with severe refractory heart failure due to severe aortic regurgitation (AR) and moderate AS, underwent CoreValve prosthesis implantation. The PHV was deployed too proximal into the left ventricular outflow tract, resulting in severe AR through the frame struts. Using the first PHV as a landmark, a second CoreValve was then deployed slightly distal to the first, with trivial residual paravalvular leak. Results: The second CoreValve expanded well with proper function. Transvalvular gradient was 8 mmHg. Both coronary ostia were patent. New mild to moderate mitral regurgitation occurred due to impingement of the anterior mitral leaflet by the first PHV. NYHA functional class improved from IV to II, maintained over the past 3 years. Echocardiography at 3 years showed normal functioning CoreValve‐in‐CoreValve prostheses, without AR or paravalvular leaks. Transvalvular gradient was 10 mmHg. Cardiac CT showed stable valve‐in‐valve protheses with no migration. Conclusion: The CoreValve prosthesis has maintained proper function up to 3 years, with no structural deterioration or migration. Treating mixed aortic valve disease with predominant AR is feasible. The concept as well as durability of the first PHV‐in‐PHV has also been demonstrated. © 2008 Wiley‐Liss, Inc.     

Intracardiac echocardiography‐guided transcatheter aortic valve replacement

Echocardiographic imaging is an essential component of successful transcatheter aortic valve replacement (TAVR). Currently, transesophageal echocardiography (TEE) is the imaging modality of choice for TAVR. However, a limitation of TEE is the need for general anesthesia and endotracheal intubation in most centers. Additionally, the TEE probe can obscure fluoroscopic views during valve positioning and deployment. Intracardiac echocardiography (ICE) has been used for imaging guidance for structural and valvular intervention, though its use has rarely been reported for primary imaging guidance during TAVR. Recently, a new volumetric three‐dimensional intracardiac ultrasound (volume ICE) system has become available with the potential for improved visualization of intracardiac structures. We describe a recent TAVR case that was successfully performed with the use of volume ICE exclusively for imaging guidance. We found that assessment of valve positioning and aortic insufficiency were comparable to that provided by conventional TEE imaging, though there were several important limitations. ICE‐guided TAVR may represent an important alternative to TEE for TAVR imaging guidance and possibly allow for less‐intensive sedation or anesthesia. © 2014 Wiley Periodicals, Inc.     

TEVAR for non‐aneurysmal thoracic aortic pathology

Objective : Management of penetrating atherosclerotic ulcers (PAU), intramural hematomas (IMH), and acute aortic dissections (AD) of the thoracic aorta remain controversial in the endovascular era. Methods : Between 2001 and 2007, patients with PAU (13 patients), and/or IMH (7 patients) were treated with thoracic endografts (TEVAR) in the endovascular suite under general anesthesia. Indications for intervention were intractable chest pain, expanding hematoma or contained rupture, or distal malperfusion. End‐points were early morbidity and mortality, incidence of endoleak, device‐related complications, and secondary interventions. Results : Of the 20 patients with a median age of 67 (25–83), 13 (65%) were men, 2 (10%) had contained aortic rupture, and 10 were symptomatic. One patient had carotid‐subclavian bypass debranching before endograft implantation. Ten patients had cerebrospinal fluid drainage. Mean length of aorta treated was 122.1 mm (range 36–300). All endografts were technically successful. Average blood loss was 50 mL. Thirty‐day mortality was 0%. Symptoms resolved in all patients; there were no neurologic complications. Average length of stay was 5 days. Mean follow‐up was 2.0 years (range 0.1–5.8). All patients remained asymptomatic. Three had early (<180 days) endoleaks: Two type II and 1 type I treated successfully with an additional cuff, which was the only patient requiring reintervention. Two patients had late (>180 days) endoleaks (type 2) observed with no aortic expansion. Two deaths at 5.4 and 5.8 years were due to severe aortic valve stenosis and metastatic lung cancer. Conclusion : TEVAR is a feasible option for repair of non‐aneurysmal thoracic aortic pathology with resolution of symptoms, no mortality, and no neurologic complications. © 2009 Wiley‐Liss, Inc.     

Cardiac resynchronization therapy for low‐flow,low‐gradient aortic stenosis

Low‐flow, low‐gradient aortic stenosis is a heterogeneous entity that encompasses truly severe aortic stenosis as well as mild‐to‐moderate aortic stenosis in which aortic valve orifice area is severely reduced primarily due to left ventricular (LV) contractile dysfunction. Under such circumstances the capacity of the LV to generate stroke‐work is severely compromised. In this case report, we describe a patient with severe LV dysfunction and ventricular dyssynchrony due to right ventricular pacing who presented with decompensated heart failure in the setting of low‐flow, low‐gradient aortic stenosis. We discuss the management of this high‐operative‐risk patient, who ultimately underwent upgrading of his dual chamber pacemaker to a biventricular pacemaker with significant echocardiographic, haemodynamic, and clinical improvement.