“Valve‐in‐valve” for the treatment of paravalvular leaks following transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is commonly associated with some degree of aortic regurgitation (AR) secondary to the presence of paravalvular leaks. We present the case of an 86‐year‐old woman diagnosed with severe aortic stenosis who underwent TAVI with a 23‐mm Edwards‐SAPIEN valve. The procedure complicated with a severe paravalvular leak following TAVI that was unresponsive to balloon postdilation. This complication was successfully managed with the implantation of a second valve of the same diameter within the first one (“valve‐in‐valve”) resulting in trivial residual AR and the absence of significant transvalvular gradient at the end of the procedure. © 2009 Wiley‐Liss, Inc.     

Valve prosthesis distortion after cardiac compression in a patient who underwent transcatheter aortic valve implantation (TAVI)

Transcatheter aortic valve implantation (TAVI) has been developed as an alternative to conventional aortic valve replacement for the treatment of symptomatic severe aortic stenosis in high‐risk patients. Nevertheless, TAVI has been associated with serious complications such as stroke, vascular injury, renal failure, and arrhythmia. Herein we describe a case of distortion of the Edward‐Sapien prosthesis (Edwards Lifesciences, USA), which was mounted on a balloon‐expandable stent, after chest compression for cardiac resuscitation in a patient who underwent TAVI for severe aortic stenosis. © 2012 Wiley Periodicals, Inc.     

Iatrogenic dissection of the ascending aorta during TAVI sealed with the corevalve revalving prosthesis

Transcatheter aortic valve implantation (TAVI) is rapidly becoming an accepted treatment option for a selected group of high risk or inoperable patients with severe aortic stenosis. However, this procedure is not without complications. We report a case of acute type A aortic dissection due to balloon aortic valvuloplasty during TAVI that was successfully sealed by the CoreValve prosthesis, thus avoiding surgical intervention.© 2011 Wiley‐Liss, Inc.     

Performance of valve-in-valve for severe para-prosthetic leaks due to inadequate transcatheter aortic valve implantation

Objectives : This study reports on mid‐term safety and performance of valve‐in‐valve implantation as rescue strategy to overcome acute PPL after TAVI. Background. Moderate to severe para‐prosthetic leaks (PPL) after transcatheter aortic valve implantation (TAVI) have been described with both self‐expandable and balloon‐expandable device.Methods : We analyzed data regarding patients who underwent valve‐in‐valve implantation, enrolled in the ongoing single‐center prospective registry of TAVI, the Padova University REVALVing experience Registry. All procedures were performed by a totally percutaneous approach, using the self‐expanding Medtronic CoreValve (Medtronic, Minneapolis, MN). Results : Out of 87 patients who underwent TAVI, six received valve‐in‐valve implantation because of persisting severe PPL, due to prosthesis malposition. In all patients, the second device was successfully deployed, with a significant reduction in aortic regurgitation: PPL was no longer appreciable in two of six patients, and it decreased from severe to mild or trivial in four patients. Four patients developed atrio‐ventricular block requiring pace‐maker implantation. At follow‐up (6–24 months) two patients died, whereas no prosthesis‐related death occurred. Transprosthesis pressure gradient, effective orifice area, and aortic regurgitation did not change at serial echocardiograms throughout the follow‐up. Conclusions : Valve‐in‐valve implantation using self‐expandable bioprosthesis seems safe and highly effective to overcome severe PPL due to prosthesis malposition early after TAVI. Moreover, the implantation of two valves does not affect the performance of prosthesis at follow‐up. © 2011 Wiley Periodicals, Inc.     

Prognostic benefit of transcatheter aortic valve implantation compared with medical therapy in patients with inoperable aortic stenosis

Objectives : To compare survival in patients with inoperable aortic stenosis who undergo transcatheter aortic valve implantation against those managed medically. Background : Without surgical correction, survival of patients with severe symptomatic aortic stenosis is poor. It is unknown whether patients undergoing transcatheter aortic valve implantation (TAVI) have a better prognosis than similar patients who are treated with medical management. Methods : Survival rates were compared in consecutive patients with severe symptomatic aortic stenosis who either underwent TAVI or continued on medical management following multidisciplinary team assessment. All patients had been turned down, or considered at unacceptably high risk, for conventional aortic valve surgery. Patients were reviewed in clinic or by telephone six monthly. Mortality data was obtained from the United Kingdom Office of National Statistics. Results : The study group included 85 patients aged 81 ± 7 years (range 62–94), of whom 48 were male. Thirty eight patients underwent TAVI while 47 patients were deemed unsuitable based on echocardiographic, angiographic, or clinical criteria and remained on medical therapy. The calculated EuroSCORE for the TAVI group was 11 ± 2 and for the medical group 9 ± 2 (P < 0.001). TAVI‐related procedural mortality was 2.6%, and 30‐day mortality was 5.2%. Among the medically‐treated patients, 14 (30%) underwent palliative balloon aortic valvuloplasty, with a trend toward improved survival (P = 0.06). During overall follow‐up of 215 ± 115 days there were a total of 18 deaths; TAVI N = 5 (13%); Medical N = 13 (28%) (P = 0.04). Conclusions : Patients with severe aortic valve disease who are not suitable for surgical aortic valve replacement have an improved prognosis if treated with transcatheter aortic valve implantation rather than continuing on medical management alone. © 2010 Wiley‐Liss, Inc.     

Stenting of acute left main coronary artery occlusion using balloon anchoring technique after transcatheter aortic valve implantation

We describe a case of acute left main stem occlusion complicating a transcatheter transfemoral aortic valve implantation. We treated this emergency using the balloon anchoring technique to insert and implant a stent in the left main stem. Transcatheter transfemoral or transapical aortic valve implantation (TAVI) is a promising treatment in patients with severe, symptomatic surgically nonamenable patients. Registries have reported 3-month mortality rates between 10 and 20%. (1) Most of the fatalities have been caused by the general poor patient condition because of advanced age or severe co-morbidities. However, TAVI has also been associated with new types of procedure-related complications such as valve embolization and cardiac perforation. Here, we describe a case of acute occlusion of the left coronary main stem following transfemoral TAVI. We treated this emergency using the balloon anchoring technique to insert and implant a stent in the left main stem.     

Delivery balloon‐induced ascending aortic dissection: An unusual complication during transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a relatively mature technique that is generally accepted as a promising treatment for inoperable patients and those who are high‐risk candidates for surgical aortic replacement. Although severe complications in the aortic valve complex, such as annular or aortic root rupture, are not frequently observed, these events could easily lead to catastrophic outcomes, and therefore remain major issues during TAVI. However, there remains a paucity of data describing these catastrophic complications because of their low incidence. We encountered the case of an 88‐year‐old woman complicated by a dissection of the ascending aorta during TAVI from an “unusual” cause: injury due to the delivery of a balloon‐expandable valve to a very narrow and heavily calcified sinotubular junction (STJ). This is the first report to demonstrate the mechanism of this complication; even a delivery balloon, not a stent frame, with low inflation pressure might injure a narrow STJ and lead to an aortic dissection. Therefore, the use of oversized delivery balloons should be avoided in patients with a narrow and calcified STJ. © 2015 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.     

Compassionate use of the self‐expandable medtronic corevalve prosthesis for the treatment of pure aortic regurgitation in a patient at prohibitive risk for surgical valve replacement

Transcatheter aortic valve implantation (TAVI) is a viable treatment option for high‐ and prohibitive‐risk patients with severe, calcified pure or predominant aortic valve stenosis, but not for pure aortic valve regurgitation. In fact, the use of TAVI for this indication is even considered unlikely due to the lack of calcium which appears essential for anchoring the stent‐valve and prevents dislocation. We report a case of a patient with severe, symptomatic pure aortic regurgitation, and a history of two previous open‐heart surgeries who was successfully treated by compassionate use implantation of an oversized Medtronic CoreValve prosthesis as an ultima ratio treatment option. © 2012 Wiley Periodicals, Inc.     

Transaortic transcatheter aortic valve implantation within a previous bioprosthetic aortic valve replacement

This report documents the first reported case of transaortic transcatheter aortic valve implantation (TAVI) using the CoreValve ReValving system (Medtronic CoreValve System, Luxembourg), within a previous bioprosthetic aortic valve replacement. TAVI has become a recognized percutaneous treatment for patients with severe native or bioprosthetic aortic valve stenosis. However, as the number of patients screened for TAVI increases, a number of patients are found with absolutely no option for peripheral arterial access, either from the femoral or subclavian routes. Transaortic CoreValve placement offers an alternate minimally invasive hybrid surgical/interventional technique when peripheral access is not possible. A CoreValve prosthesis was implanted via the transaortic route in an 81‐year‐old woman with severe bioprosthetic aortic valve stenosis (21 mm Mitroflow pericardial valve, peak instantaneous gradient of 99 mmHg, effective valve orifice area (EOA) of 0.3 cm², as ilio‐femoral and left subclavian angiography revealed small calibre vessels (<6 mm). Access was achieved via a mini thoracotomy via the left anterior second intercostal space. The procedure went without complication. Post procedure the patient was transferred directly to the Cardiac Care Unit for recuperation. Post procedure echocardiography showed that the TAVI was well positioned with no para‐valvular leak and a reduction in peak instantaneous gradient to 30 mmHg and an increase in EOA to 1.5 cm². She was discharged on the third post‐procedural day in sinus rhythm with a narrow QRS complex. CoreValve implantation within previous surgical bioprosthesis is now an established treatment. The transaortic approach to transcatheter implantation is a promising recent development, when due to anatomical reasons, transfemoral or subclavian TAVI is not feasible. © 2011 Wiley‐Liss, Inc.     

Coronary obstruction following transcatheter aortic valve‐in‐valve implantation for failed surgical bioprostheses

Transcatheter aortic valve implantation (TAVI) for failed surgical bioprostheses, or “valve‐in‐valve” implantation, is a therapeutic option for high‐risk patients. While coronary occlusion during TAVI for native aortic stenosis has been described, in the setting of valve‐in‐valve implantation the bioprsthetic posts may be protective against this complication. We describe the first two cases of coronary occlusion following valve‐in‐valve therapy, both occurring during treatment of degenerated Mitroflow bioprostheses. Aortic root anatomy, coronary ostial position, and the specifics of the bioprosthetic valve type need to be considered in assessing and preventing this rare complication. © 2011 Wiley‐Liss, Inc.     

Outcomes of patients with severe aortic stenosis at high surgical risk evaluated in a trial of transcatheter aortic valve implantation

Recent randomized clinical trials have demonstrated that transcatheter aortic valve implantation (TAVI) reduces mortality in high-risk patients with aortic stenosis who are not candidates for aortic valve replacement (AVR). In similar patients who are acceptable candidates for AVR, TAVI provides equivalent outcomes to AVR. In this study, 900 patients with severe aortic stenosis at high surgical risk were evaluated as possible candidates for TAVI. Of these, 595 (66.1%) had neither TAVI nor AVR and constituted the medical arm. In addition to the best available conservative care, 345 patients (39.3%) in this group had balloon aortic valvuloplasty. The AVR arm consisted of 146 patients (16.2%) and the TAVI arm of 159 patients (17.6%). The AVR group had significantly lower clinical risk compared to the medical and TAVI groups, with lower mean age, Society of Thoracic Surgeons score, and logistic European System for Cardiac Operative Risk Evaluation score. Patients in the medical and balloon aortic valvuloplasty group had significantly higher B-type natriuretic peptide levels compared to those in the AVR and TAVI groups and had, on average, lower ejection fractions. The medical and balloon aortic valvuloplasty group was followed for a median of 206 days; the mortality rate was 46.6% (n = 277). The AVR group was followed for 628 days; 39 patients died (26.7%). In 399 days of follow-up, the mortality rate in the TAVI group was 30.8% (n = 49). In conclusion, patients with severe AS who did not undergo TAVI or AVR had high mortality. In properly selected patients, TAVI and AVR improve outcomes. Renal failure is the strongest correlate for adverse outcomes, irrespective of treatment group.     

Time to revisit role of transcatheter balloon aortic valvuloplasty: a bridge-therapy to subsequent treatment case report

Recently there has been a noticeable resurgence in the usage of percutaneous balloon aortic valvuloplasty (BAV) by the development of less invasive endovascular therapies including transcatheter aortic valve implantation (TAVI). We performed BAV in a 91-year-old man with end-stage severe symptomatic aortic stenosis (AS) and an impending abdominal aortic aneurysm (AAA) rupture who had been refused surgical treatment because of the comorbidities with stage V chronic kidney disease (CKD) and severe left ventricular dysfunction. Improvement in hemodynamics and kidney function was observed after BAV. Subsequently, we performed endovascular aneurysm repair (EVAR) successfully for AAA using iodinated contrast. No deterioration of kidney function was confirmed after the procedure. The patient was discharged without any adverse events. At present, the possibilities of TAVI or surgical aortic valve replacement (s-AVR) are under consideration as the definitive therapy for the upcoming aortic valve restenosis. In conclusion, this inoperable patient with multiple comorbidities was successfully treated, at lower risk, by catheter-based two-stage therapy.     

Paravalvular leak closure for persisting aortic regurgitation after implantation of the corevalve transcatheter valve

Significant aortic regurgitation after TAVI results in lack of symptomatic and prognostic benefit from the procedure and generally requires intervention. While most of the regurgitations can be successfully targeted with standard techniques, occasional patients have restrictive calcification resistant to post‐dilatation and significant regurgitation persists. We present a case of refractory aortic regurgitation successfully treated with percutaneous paravalvular leak closure. An 81‐year‐old man with symptomatic severe aortic stenosis underwent a transfemoral CoreValve TAVI in December 2009. He had significant aortic regurgitation refractory to medical and interventional therapy including balloon post‐dilatation, valve repositioning and valve‐in‐valve reimplantation. Aortic regurgitation remained severe and therefore in early 2013, we proceeded with an attempted percutaneous closure of the residual paraprosthetic leak. Using 6‐French femoral access and a Terumo wire, the defect was successfully crossed with a 4‐French Multipurpose catheter and an 8 mm Amplatzer Vascular Plug 4 device (St. Jude Medical) was deployed through this catheter, resulting in abolition of aortic regurgitation on aortography and TOE, with associated excellent clinical response. Refractory paravalvular aortic regurgitation post CoreValve implantation can be successfully treated using the Amplatzer Vascular Plug 4 device. © 2013 Wiley Periodicals, Inc.     

Transseptal Mitral Valve Replacement after Transcatheter Aortic Valve Implantation

We report a case of mitral valve replacement in a patient who had previously undergone transcatheter aortic valve implantation. A transseptal approach was used to avoid displacing the aortic prosthesis. Because of the small mitral annulus, a bioprosthetic aortic valve was used in reverse position for mitral valve replacement. The procedure did not interfere with the existing prosthesis, and a follow-up echocardiogram showed that both prosthetic valves were functioning well.To the best of our knowledge, this is the first report of mitral valve replacement in a patient who had a preceding transcatheter aortic valve implantation. We believe that the transseptal approach is promising for mitral valve replacement in such patients. Moreover, using a bioprosthetic aortic valve in reverse position is an option for mitral valve replacement when the mitral annulus is too small for placement of a standard bioprosthetic mitral valve.Key words: Aged, 80 and over; aortic valve; bioprosthesis; calcinosis/complications; cardiac surgical procedures; heart atria/surgery; heart valve prosthesis implantation; mitral valve insufficiency/surgeryTranscatheter aortic valve implantation (TAVI) is currently emerging as a valuable option to treat high-risk patients with severe, symptomatic aortic stenosis.¹ The number of patients receiving TAVI has increased dramatically over a short period of time because of the promising advances in this new technology and the growing number of high-risk, elderly patients with multiple comorbidities, who are better suited for a minimally invasive procedure. Consequently, cardiac surgeons must care for an increasing number of patients who have undergone TAVI. Subsequent cardiac procedures in the setting of previous TAVI pose a challenge due to the risks of procedural interference with—and postprocedural functional impairment of—the previous aortic prosthesis. The following case illustrates an effective method of performing a mitral valve replacement in the setting of previous TAVI.     

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.     

Late subannular aortic root rupture following transcatheter aortic valve implantation presenting as ST elevation myocardial infarction

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis. Here, we present a case of late aortic root rupture presenting as ST‐elevation myocardial infarction five weeks following successful TAVI. Aortic root rupture is a rare complication of TAVI, which occurs in ～1% of procedures and usually arises during or soon after the procedure and is associated with high mortality (～50%). Early recognition of late‐presenting complications related to TAVI, including aortic root rupture, is essential for specialists and nonspecialists. © 2016 Wiley Periodicals, Inc.     

Transcatheter aortic valve implantation without balloon predilatation

Balloon predilatation has been regarded as an essential step before implanting the self‐expandable prosthesis during transcatheter aortic valve implantation (TAVI). Recent evidence showed that without balloon predilatation, an implantation success rate of >95% could be achieved. We report two cases in which balloon predilatation was not performed initially during TAVI but eventually required it to facilitate device crossing and implantation. They illustrated the importance of case selection and alerted us the potential limitation in performing TAVI without balloon predilatation. © 2013 Wiley Periodicals, Inc.     

Who is the right patient for TAVI?

Transcatheter aortic valve implantation (TAVI) has rapidly emerged as a valid therapeutic option for patients with severe symptomatic aortic stenosis who are high risk or ineligible for conventional surgical aortic valve replacement. Despite its minimally invasive nature, TAVI is invariably associated with complications in these old patients that may affect outcomes. Although the success of TAVI is determined by multiple factors, good screening and appropriate patient selection is crucial. Selection of the right patient includes the determination of risk levels and feasibility of a safe procedure in each individual case. Here, we describe below our critical appraisal of patient selection for TAVI.     

Transfemoral aortic valve implantation in pure native aortic valve insufficiency using the repositionable and retrievable lotus valve

Transfemoral aortic valve implantation (TAVI) for the treatment of pure native aortic insufficiency is not routine clinical practice. Absent cusp calcification, missing landmarks in combination with no perfect valve control during release with first‐generation TAVI devices resulted in a high rate for need of a second valve or relevant residual aortic insufficiency. We report the first case with a native pure aortic valve insufficiency at high surgical risk successfully treated by implantation of the repositionable and completely retrievable Lotus valve, resulting in a well‐controlled and safe procedure with no residual aortic insufficiency. © 2015 Wiley Periodicals, Inc.