The first love,you never forget. The last heart valve,you might remember better than the first

• Valve‐in‐valve (VIV) transcatheter aortic valve replacement (TAVR) does not increase cerebrovascular risk compared with TAVR in native aortic valves; the only predictors of new brain lesions were age and postdilatation.
• Wise choice of the biological valve at the time of surgical aortic replacement, routine use of cerebral protection devices, and new therapeutic paths may be important.
• Larger studies are needed, hopefully with systematic postdilatation or bioprosthetic valve fracture in cases of residual high transvalvular gradients after VIV TAVR.

     

Urgent transcatheter aortic valve replacement for severe acute aortic regurgitation following open mitral valve surgery

Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at high risk for conventional surgery. We describe the first use of TAVR to treat iatrogenic severe acute pure aortic incompetence following mitral valve surgery. A 71‐year‐old gentleman developed life‐threatening acute aortic regurgitation (AR) within hours of a very challenging fifth open heart mitral valve replacement. Careful inspection of echocardiographic and computed tomographic imaging identified the cause as a disrupted left coronary cusp at the commissure caused by the surgical mitral annular reconstruction. Medical management with afterload reduction failed with recurrent pulmonary edema, and a sixth open heart surgery was deemed prohibitively high risk. The lack of aortic annular calcium onto which anchors a transcatheter valve was a concern for TAVR. However, we postulated that the struts of the mitral valve bioprosthesis would offer some support to the TAVR valve. We opted for a self‐expanding system because of concerns about potential unfavorable interaction between the balloon onto which balloon‐expandable bioprosthesis is mounted and the struts of the mitral bioprosthesis, and because the Evolut R system has additional anchoring points at the crown which might enhance transcatheter valve stability in the non‐calcified annulus, compared with the Edwards Sapien system. Transfemoral TAVR, performed with a Medtronic Evolut R 34 mm system under general anesthesia and using moderately rapid ventricular pacing, was successful with minimal residual AR. On follow‐up 1 month later the patient was asymptomatic, and the aortic and mitral bioprostheses were functioning normally on echocardiogram.     

Successful treatment of a paravalvular leak with balloon cracking and valve‐in‐valve TAVR

Transcatheter heart valve implantation into degenerated bioprosthetic valves (ViV‐THV implantation) has become an established procedure for high risk patients. In general, paravalvular leak (PVL) is a contraindication for valve‐in‐valve‐TAVR (ViV‐TAVR). Herein, we report on a 81‐year‐old patient presenting with acute heart failure for a failing aortic bioprosthesis (Medtronic Mosaic 27 mm). Intraoperative transesophageal echocardiography during urgent ViV‐TAVR revealed a PVL previously not detected. After transfemoral implantation of a 26 mm‐Evolut‐R, balloon‐fracturing of the bioprosthetic ring was performed using a 24 mm True Dilatation balloon for treatment of the PVL. Afterward, left ventricular to aortic peak‐to‐peak pressure gradient measured 2–4mmHg. Transesophageal echocardiography merely revealed trace PVL. Aortic root angiography showed no PVL. At discharge, echocardiography measured a transprosthetic mean gradient of 5mmHg detecting no PVL. Intentional ring‐fracturing of an aortic valve prostheses may prove not only to be effective in lowering transvalvular gradients after valve‐in‐valve‐TAVR, but may also be a tool to treat PVL alongside degenerated surgical aortic bioprostheses in certain patients.     

Complications after Transfemoral Transcatheter Aortic Valve Replacement with a Balloon‐Expandable Prosthesis: The Importance of Preventative Measures and Contingency Planning

Transcatheter aortic valve replacement (TAVR) with balloon‐expandable Edwards‐SAPIEN valve was superior to standard therapy in inoperable patients and noninferior to surgical aortic valve replacement in high surgical‐risk, but operable patients, with severe symptomatic aortic stenosis in the randomized controlled PARTNER trial. Since the first case of TAVR with a balloon‐expandable valve in 2002, several groups have reported their experience with balloon‐expandable valves with high‐procedural success. In the United States, the balloon‐expandable Edwards‐SAPIEN valve is the only transcatheter heart valve approved by the FDA for commercial use. Moreover, this is only in high‐risk inoperable patients. Despite increasing experience with the TAVR procedure, it can be associated with complications, which can be technically challenging, even for an experienced operator. Complications associated with TAVR include vascular complications, valve malpositioning, regurgitation, embolization, coronary compromise, conduction abnormalities, stroke/transient ischemic attack, acute kidney injury, cardiac tamponade, and hemodynamic collapse. A thorough understanding of the procedure is essential for pre‐emptive planning for procedural complications and early identification and management of complications are necessary for procedural success. We hereby review our experience of transfemoral TAVR with balloon‐expandable valves, offer practical tips to maximize the likelihood of procedural success, describe pre‐emptive strategies to prevent peri‐procedural complications and bailout measures to manage them, should they occur. © 2018 Wiley Periodicals, Inc.     

Intraprocedural balloon dilation of the direct flow medical transcatheter aortic valve: First United States experience

Optimization of hemodynamics during transcatheter aortic valve replacement (TAVR) using the commercially available balloon expandable and self‐expanding valves is often accomplished through post‐dilation of the valves' metallic frame. The direct flow medical (DFM) valve is a uniquely designed second‐generation TAVR prosthetic without a rigid metallic frame. It is not widely known whether balloon dilation of this valve is beneficial when valve hemodynamics after initial deployment suboptimal due to valve underexpansion. We present the first two US patients who underwent TAVR using the DFM valve who had underexpansion in the setting of bulky leaflet calcification that resulted in elevated valve gradients and were treated successfully using intraprocedural balloon dilation. © 2016 Wiley Periodicals, Inc.     

A word of caution using self‐expanding transcatheter aortic valve‐frame infolding

Transcatheter aortic valve replacement has become a mainstay alternative to surgical aortic valve replacement in patients with severe aortic stenosis at high and intermediate surgical risk. Two commercially approved valves are available in the United States: balloon‐expandable and self‐expanding. We report here a rare complication of a self‐expanding Evolut PRO (Medtronic, Minneapolis, Minnesota) valve failing to expand due to nitinol frame infolding. This results in a malopposed valve with a severe paravalvular leak, even though treated successfully with balloon valvuloplasty. It is important to recognize the characteristic angiographic signature of this complication—the “straight line” sign—and how to avoid this potentially serious complication by balloon valvuloplasty or by recapture and deployment of a new valve.     

Salvaging lowermost deployment of an acurate device during transcatheter aortic valve replacement with balloon and lasso pull techniques

Transcatheter aortic valve replacement (TAVR), also known as transcatheter aortic valve implantation (TAVI), is being used with increasing frequency in patients with severe aortic stenosis at high or prohibitive surgical risk. A number of devices are becoming available for TAVR, and competence in using them is mandatory to maximize the safety and efficacy of TAVR, while individualizing device selection in keeping with patient features. The ACURATE TF is a novel promising device for transfemoral TAVR. However, its peculiar features may require additional maneuvers in case of complications. We hereby report the case of a patient undergoing transfemoral TAVR with the ACURATE TF device, in whom lowermost deployment was complicated by massive aortic regurgitation. With two separate remedial actions, the balloon pull and lasso techniques, we were able to pull back the device and significantly reduce post‐TAVR aortic regurgitation. Awareness of this complication and the possible use of these two techniques may increase the safety and efficacy of TAVR with this and other new devices. © 2015 Wiley Periodicals, Inc.     

Perceval sutureless valve migration treated by valve‐in‐valve with a CoreValve Evolut Pro

In the last years, the use of sutureless devices in frail patients with severe aortic stenosis has increased thanks to their “easier and faster” technique of implantation in comparison to conventional surgery. Results from metanalysis show comparable outcomes in comparison to transcatheter aortic valve replacement (TAVR) in terms of mortality, stroke incidence, and rate of pace‐maker implantation. The incidence of para‐valvular leak (PVL) is even lower for sutureless devices than for TAVR. The few cases described are generally due to incomplete decalcification or incorrect valve sizing and consequent stent distortion. To our knowledge this is the first case describing PVL with massive aortic regurgitation due to early partial embolization of a Perceval valve and its successfully treatment with valve‐in‐valve by using a self‐expanding TAVR device.     

Transcatheter aortic valve replacement: The year in review 2016

Transcatheter aortic valve replacement (TAVR) continued to make major strides in 2016, simultaneously expanding its application to lower risk patients as well as more technically challenging subsets of patients with aortic stenosis (AS). The two major accomplishments this year were the establishment of TAVR as the preferred treatment strategy over surgical aortic valve replacement (SAVR) in intermediate risk patients, and initial signals that TAVR and SAVR may be clinically equivalent in low‐risk populations. Meanwhile, there is continued expansion of TAVR to challenging clinical subsets (bicuspid aortic valve [BAV], patients with concomitant advanced coronary artery disease [CAD], and failed surgical bioprostheses), and encouraging initial experiences with newer transcatheter heart valve systems. This paper summarizes the major research studies published on TAVR in 2016.

     

Assessing the risk of an anomalous circumflex artery using balloon aortic valvuloplasty prior to transcatheter aortic valve replacement

Anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva or proximal right coronary artery (RCA) is a well‐known anatomic variation. Although the condition is usually benign, there is risk for compression of the anomalous artery by a prosthetic valve in patients undergoing aortic valve replacement (AVR). In more recent years, balloon aortic valvuloplasty (BAV) has been performed prior to transcatheter aortic valve replacement (TAVR) to serve as a diagnostic tool in the evaluation of symptom relief and procedural risks prior to definitive therapy with TAVR. However, the literature regarding BAV utilization in the assessment of coronary artery anomalies prior to TAVR is scarce. Our case illustrates the importance of performing preoperative BAV to assess the safety of a TAVR procedure in patients with coronary anomalies. Herein, we present a case of a patient who underwent BAV with selective angiography of her anomalous circumflex artery. During balloon inflation, the anomalous circumflex artery was transiently occluded, with complete resolution with balloon deflation. Given these findings, the patient was deemed to be unsuitable for TAVR and offered surgical AVR. This case demonstrates that patients with anomalous coronary circulation may require BAV with selective angiography to fully evaluate risk of coronary occlusion with TAVR.     

Balloon valvuloplasty treatment of an infolded CoreValve

Transcatheter aortic valve replacement is an approved treatment for select patients with severe aortic stenosis. A rare complication of self‐expanding transcatheter heart valves (THVs) is infolding of the valve stent frame, which results in a malopposed segment, perivalvular aortic insufficiency, and possibly leaflet dysfunction. We report here a successful case of balloon valvuloplasty treatment for severe infolding of a self‐expandable THV in the aortic position, restoring stent frame geometry and leaflet function. © 2015 Wiley Periodicals, Inc.     

Transcatheter aortic valve in valve implantation with bioprosthetic valve fracture

Valve‐in‐valve transcatheter aortic valve replacement (VIV TAVR) has emerged as a preferable option for high surgical risk patients requiring redo aortic valve replacement. However, VIV TAVR may restrict flow, especially in small native aortic valves. To remedy this, bioprosthetic valve fracture has been utilized to increase the effective orifice area and improve hemodynamics. We present three cases in which bioprosthetic valve fracture was used to increase hemodynamic flow in VIV TAVR procedures.     

Stroke associated with surgical and transcatheter treatment of aortic stenosis: a comprehensive review

Stroke is a potential complication of treating patients with aortic stenosis via surgical aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR), and balloon aortic valvuloplasty. Because there are limited and heterogeneous data on the incidence, risk factors, and outcomes of stroke among patients being treated for aortic stenosis, we performed a comprehensive review of the literature. The risk of stroke after AVR in the general population is approximately 1.5%, and the risk is increased (to approximately 2% to 4%) in older and higher-risk patients. Strokes were reported in 1.5% to 6% of patients treated with TAVR, and in the only randomized trial of AVR versus TAVR, there was an increased risk of 30-day strokes (minor and major strokes and transient ischemic attacks) with TAVR (5.5% vs. 2.4%, p = 0.04).     

A very rare vascular complication of the Edwards expandable eSheath during transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) has revolutionized the management of severe symptomatic aortic valve stenosis. TAVR is now indicated as an alternative to surgical replacement in a wide risk profile ranging from high to low surgical risk. Although vascular complications have decreased in frequency over time, with the introduction of lower profile delivery systems and sheaths, they remain one of the most frequently encountered and serious complications of TAVR. Patient-specific predisposing factors have been well characterized. However, much less is known about device-specific complications. Awareness of the possible device-related complications may lead to earlier identification, prompt management, and better outcomes. We report a previously unreported complication of the Edwards expandable eSheath that lead to avulsion of the external iliac artery following successful TAVR with a 29-mm Edwards Sapien 3 transcatheter heart valve. Bleeding was promptly controlled with an occlusion balloon and emergency surgical repair was required with a favorable outcome.     

CoreValve Prosthesis Causes Anterior Mitral Leaflet Perforation Resulting in Severe Mitral Regurgitation

Percutaneous transcatheter aortic valve replacement (TAVR) has become an alternative to surgical therapy for patients with severe aortic stenosis and high operative risk, but it is associated with specific complications. We report the case of a 72-year-old man who underwent the procedure without complications; however, 45 days after the procedure, he was admitted to the hospital with symptoms of heart failure secondary to severe mitral regurgitation. Necropsy findings showed prosthesis malposition and perforation of the anterior mitral leaflet caused by the contact of the stent of the CoreValve prosthesis (Medtronic, Minneapolis, MN). We discuss TAVR complications, specifically regarding low positioning of the prosthetic valve.     

Balloon-Expandable Prostheses for Transcatheter Aortic Valve Replacement

The implantation of a transcatheter heart valve (THV) through a balloon-expandable system played a major role in the early stages of transcatheter aortic valve replacement (TAVR). The technology consists of sewing a foldable biological cardiac valve inside a metallic stent frame, and then crimping the device into a balloon in order to implant the valve at the level of the aortic annulus through balloon inflation. The use of balloon-expandable valves underwent a rapid expansion in the years following the pioneering experience of 2002, and recent large multicenter trials and registries have confirmed the safety and efficacy of TAVR using balloon-expandable valves. The randomized Placement of Aortic Transcatheter Valves (PARTNER) trial showed both the superiority and non-inferiority of TAVR with the balloon-expandable Edwards-Sapien system compared to medical treatment (non-operable patients) and surgical aortic valve replacement (high risk patients), respectively. Balloon-expandable valves have been associated with excellent hemodynamic results (residual mean gradient < 15 mm Hg in most cases), though residual paravalvular aortic regurgitation is frequent (trivial or mild in the majority of patients, moderate or severe in < 10%). Valve durability studies with up to 5-year follow-up have shown maintained valve hemodynamics over time with only a minimal decrease in valve area and no increase in aortic regurgitation. Future improvements in the balloon-expandable THV technology such as implementing anti-paravalvular leak features (ex. Sapien 3 valve), and showing its efficacy for the treatment of non-high risk patients (ongoing PARTNER II trial) will probably lead to broader use in a lower risk population in the near future.     

Double trouble: A case of periprocedural detection of intracardiac thrombus and aortic root dissection during emergent transfemoral TAVR

We report a case of emergency transcatheter aortic valve replacement (TAVR) in a 65‐year‐old patient presenting with decompensated severe aortic stenosis. Transesophageal echocardiography (TEE) was used effectively to obtain measurements of the aortic annulus and for intra‐procedural guidance. At baseline, we detected a left atrial appendage thrombus and a localized aortic root dissection after balloon valvuloplasty. The case highlights the important role that TEE may play during TAVR procedures.     

Bioprosthetic aortic valve leaflet disruption with high energy electrocautery to prevent coronary artery obstruction during valve‐in‐valve transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is well‐established for the treatment of bioprosthetic aortic valve stenosis (AS) in high surgical risk patients. Coronary artery obstruction from displacement of the bioprosthetic valve leaflets during valve‐in‐valve (VIV) TAVR is a rare, but potentially fatal, complication. Recently, the bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure was developed as a method for disrupting bioprosthetic leaflets in patients undergoing VIV TAVR at high risk for coronary obstruction. This case describes a successful VIV TAVR utilizing a simplified concept of the BASILICA technique in a patient where the full procedure could not be completed.     

Simultaneous transapical transcatheter aortic valve replacement and transcatheter mitral valve replacement for native valvular stenosis

Transcatheter aortic valve replacement (TAVR) is well established for patients who cannot undergo surgery (Leon et al., N Engl J Med 2010;363:1597) or are high risk for surgery (Smith et al., N Engl J Med 2011;364:2187–2198). Experience with the TAVR procedure has led to recent reports of successful transcatheter mitral valve replacement (TMVR) procedures (Cheung et al., J Am Coll Cardiol 2014;64:1814; Seiffert et al., J Am Coll Cardiol Interv 2012;5:341–349) separately or simultaneously with the TAVR. However, these reports were of simultaneous valve‐in‐valve procedures (Cheung Anson, et al. J Am Coll Cardiol 2013;61:1759–1766). A recent report from Portugal also reported simultaneous transpical implantation of an inverted transcatheter aortic valve‐in‐ring in the mitral position and transcatheter aortic valve (Hasan et al., Circulation 2013;128:e74–e76). There has been an experience of TMVR only in native mitral valve for mitral valve stenosis, but none in both aortic and mitral valves. We report the first in human case of simultaneous transapical TAVR and TMVR in native valves secondary to valvular stenosis. Our patient was not a candidate for percutaneous balloon mitral valvuloplasty secondary to a high Wilkins Score. Sizing of the aortic valve was based on the transesophageal echocardiogram (TEE), whereas sizing of the mitral valve was based on TEE measurements and balloon inflation during left ventriculography. © 2015 Wiley Periodicals, Inc.     

A novel approach to extraction of a large thrombus on the intraventricular guide‐wire during transcatheter aortic valve replacement

For appropriate patients with severe symptomatic aortic stenosis with a prohibitively high surgical risk, trans‐catheter aortic valve replacement (TAVR) is now established as a viable option. Thrombosis on the intra‐ventricular guide‐wire during TAVR is a recognized complication (Wiper et al., Cardiovasc Revasc Med 2014). There is an obvious potential for embolization with particular concern for stroke in this situation. We describe a case in which a >1cm thrombus was noted on the intra‐ventricular guide‐wire by trans‐esophageal echocardiogram (TEE) during a TAVR procedure. Balloon aortic valvuloplasty was still performed and an Edwards Sapien valve was deployed. After valve deployment a multi‐purpose guiding catheter was advanced with continuous suction. The guide‐wire and thrombus were withdrawn inside the guiding catheter. The guide‐wire and catheter were removed as a single unit, allowing the thrombus to be safely retrieved. We believe that this is a novel technique of aspiration thrombectomy in this potentially hazardous clinical circumstance. As our experience with TAVR increases, so does our experience with the complications. In the PARTNER trial there was a higher rate of neurological events in TAVR patients than those who had open aortic valve replacement (Smith et al. N Engl J Med 2011;364:2187–2198.). This may be related to peri‐procedural formation of thrombus and subsequent embolization. We report a case where a large guide‐wire thrombus identified during TAVR was successfully removed using a novel approach, preventing a potentially major stroke in this high‐risk patient. © 2015 Wiley Periodicals, Inc.