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.     

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 The guide‐wire and thrombus were withdrawn inside the guiding catheter.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.     

Acute fulminant hemolysis after transcatheter mitral valve replacement for mitral annular calcification

Transcatheter mitral valve replacement (TMVR) is emerging as an alternative treatment strategy to surgery for patients with severe mitral annular calcification (MAC) who are not candidates for traditional mitral valve surgery. Paravalvular leak (PVL) is common following TMVR for severe MAC and can lead to heart failure symptoms and/or intravascular hemolysis, the latter of which usually is clinically stable. We report the case of a 67‐year‐old woman with symptomatic severe aortic stenosis and mitral stenosis with MAC in the setting of prior chest irradiation who was treated initially with transcatheter aortic valve replacement followed by TMVR at a later date (Sapien S3 system; Edwards Lifesciences). Immediately following TMVR, she developed acute profound hemolysis which manifested with hemoglobinuria, transfusion‐dependent anemia, and acute renal failure requiring renal replacement therapy. She was treated with post‐dilation balloon valvuloplasty after failed transcatheter PVL closure 10 days following TMVR with resulting improvement in the PVL. The hemolytic anemia resolved and renal function recovered without the need for continued hemodialysis 2 months later and stabilization of glomerular filtration rate at 6 months. This case highlights a potential severe complication of TMVR in MAC and suggests that improvement in hemolysis and late recovery of renal function may occur following treatment of PVL.     

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.     

Early experience of implantation of the new CoreValve® Evolut™ in degenerated bioprosthetic aortic valves

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis in high‐risk patients. The PARTNER trial demonstrated equivalent 1‐year survival rates between patients randomized to TAVI versus conventional surgery (Leon et al., N Engl J Med 2010;363:1597–1607), with sustained benefit up to 2 years (Makkar et al., NEJM 2012;366:1696–1704). Recently, the ADVANCE registry cited all‐cause mortality rates of 4.5%, 12.8%, and 17.9% at 30‐days, 6 months, and 1‐year following TAVI in 1,015 high‐risk patients (Linke, TCT 2012, 2012). In addition, TAVI was demonstrated to be a feasible treatment for severe native valve regurgitation in a series of 31 high‐risk patients. The all‐cause 30‐day mortality rate was 6.4%, with a 30‐day major stroke rate of 6.4%. At 1‐year, the all‐cause mortality rate was 12.5% (Roy et al., J Am Coll Cardiol 2012;60(17S):B264). We report the successful transcatheter implantation of the new CoreValve^® Evolut^? in two patients with regurgitant aortic bioprostheses. © 2013 Wiley Periodicals, Inc.     

Simultaneous transfemoral transcatheter aortic valve replacement and trans‐septal mitral valve‐in‐ring implantation after partial laceration of an Alfieri stitch

In patients with an Alfieri Stitch transcatheter mitral valve replacement (TMVR) may be difficult due to the double orifice configuration of the mitral valve. We report a case of simultaneous and completely percutaneous TAVR and TMVR using LAMPOON‐related techniques prior to TMVR to allow for optimal valve deployment.     

Transcatheter implantation of SAPIEN 3 valve in native right ventricular outflow tract for severe pulmonary regurgitation following tetralogy of fallot repair

Pulmonary valve replacement (PVR) is indicated in patients with significant pulmonary regurgitation (PR), stenosis (PS), or mixed pulmonary valve disease. While once an exclusively surgical procedure, many patients can undergo transcatheter PVR (TPVR) with excellent early outcomes (Haas et al. 2013, Clin. Res. Cardiol. Off. J. German Cardiac Soc. 102:119–128; Kenny et al. 2011, J. Am. Coll. Cardiol. 58:2248–2256; Cheatham et al. Circulation 2015, 131:1960–1970). The available transcatheter options continue to expand, but the majority of cases performed in the United States involve the use of FDA approved Melody valve (Medtronic; Minneapolis, MN) or the SAPIEN (Edwards Lifesciences; Irvine, CA) family of valves. The SAPIEN 3 valve (S3) recently received FDA approval for transcatheter aortic valve replacement. We report the first S3 implantation in the pulmonary position for treatment of chronic pulmonary regurgitation and progressive right ventricular dilation in an 18 year old male with repaired Tetralogy of Fallot. © 2016 Wiley Periodicals, Inc.     

First in human percutaneous implantation of a balloon expandable transcatheter heart valve in a severely stenosed native mitral valve

Transcatheter implantation of a balloon expandable valve in calcified severely stenosed native mitral valves has recently been described. The two cases reported so far utilized the surgical transapical approach generally used for transapical transcatheter aortic valve replacement. A percutaneous approach has not been published. We report the first successful percutaneous implantation of a balloon expandable transcatheter valve in the native mitral valve without a surgical incision. © 2014 Wiley Periodicals, Inc.     

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.     

First report of a simultaneous transcatheter mitral valve‐in‐valve and aortic valve replacement in a left ventricular assist device patient

Transcatheter aortic valve replacement is standard of care for patients with severe aortic stenosis at high risk for surgical aortic valve replacement. Although not intended for treatment of primary aortic insufficiency, several transcatheter aortic valve prostheses have been used to treat patients with severe aortic insufficiency (AI), including patients with left ventricular assist devices (LVAD), in whom significant AI is not uncommon. Similarly, transcatheter valve replacements have been used for valve‐in‐valve treatment, in the pulmonary, aortic, and mitral positions, either via a retrograde femoral approach or antegrade transseptal approach (mitral valve‐in‐valve). In this case report, we report an LVAD patient with severe aortic insufficiency and severe bioprosthetic mitral prosthetic stenosis, in whom we successfully performed transfemoral aortic valve replacement and transfemoral mitral valve‐in‐valve replacement via a transseptal approach. © 2017 Wiley Periodicals, Inc.     

Percutaneous closure of acute aorto‐right ventricular fistula following transcatheter bicuspid aortic valve replacement

We report a case of acute aorto‐right ventricular fistula following transcatheter bicuspid aortic valve replacement and subsequent percutaneous closure. The diagnosis and treatment of this rare complication is illustrated through multi‐modality imaging. We hypothesize that the patient's heavily calcified bicuspid aortic valve anatomy led to asymmetric deployment of the transcatheter aortic valve replacement (TAVR) prosthesis, traumatizing the right sinus of Valsalva at the distal edge of the TAVR stent and ultimately fistulized to the right ventricle. The patient acutely decompensated with heart failure five days after TAVR and underwent emergent intervention. The aorto‐right ventricular fistula was closed using an 18‐mm septal occluder device with marked clinical recovery. Transcatheter closure is a viable treatment option for acute aorto‐right ventricular fistula. © 2016 Wiley Periodicals, Inc.     

经导管主动脉瓣置换的介入瓣膜的现状及展望

经导管主动脉瓣置换术（TAVR）经过最近几年快速发展已经取得巨大进步。迄今为止全球接受TAVR的患者数已近3万例,已成为无法耐受传统手术患者的标准备选治疗措施。从目前已临床应用的介入瓣膜到正在实验研究的新型介入瓣膜可以看出,未来介入瓣膜的发展目标是尺寸更小、长期有效、安全性高、并发症少、操作简单及定位精准。随着TAVR的推广,新型介入瓣的研发,操作者经验的积累,以及长期随访的开展,将给TAVR提供更科学的病例选择标准,减少介入手术的相关并发症,提高更安全有效的治疗效果。未来此项技术还会逐渐扩大适用人群的范围,成为代替传统的主动脉瓣置换术举足轻重的治疗措施。     

Fracture of small Mitroflow® aortic bioprosthesis following valve‐in‐valve transcatheter aortic valve replacement with ACURATE neo valve—From bench testing to clinical practice

Valve‐in‐valve (ViV) transcatheter procedures have emerged as a feasible, less‐invasive treatment option for bioprosthetic structural valve deterioration. However, in the presence of a small bioprosthesis, a significant residual gradient after ViV procedures often occurs and has been associated with poorer clinical outcomes. We report the use of the self‐expandable supra‐annular ACURATE neo? valve to treat degenerated Mitroflow (Sorin) aortic bioprosthesis with severe residual elevated gradients followed by valve fracture with a postdilation using a noncompliant balloon leading to significant reduction in residual gradients. In conclusion, the use of ACURATE neo? valve followed by the controlled fracture of the surgical bioprosthesis frame with a noncompliant balloon is a safe and effective approach for patients with Mitroflow® failing valves and residual elevated gradient after transcatheter aortic valve replacement.     

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.     

Percutaneous alcohol septal ablation to acutely reduce left ventricular outflow tract obstruction induced by transcatheter mitral valve replacement

Transcatheter implantation of balloon expandable valves in native mitral valves (MV) has been performed in patients with severe MV annular calcification who are not good candidates for standard surgical MV replacement. Significant left ventricular outflow tract (LVOT) obstruction with hemodynamic compromise has been described as one of the potential complications of transcatheter MV replacement. Surgical rescue carries significant risk in this high‐risk patient population. We describe a percutaneous technique to acutely decrease transcatheter MV replacement‐induced LVOT obstruction. © 2016 Wiley Periodicals, Inc.     

Transcatheter aortic valve replacement in unicuspid aortic valve stenosis

Unicuspid aortic valve (UAV) offers unique challenges to transcatheter aortic valve replacement (TAVR), due to asymmetric expansion and apposition of the prosthesis during implantation. Although TAVR in bicuspid is now a well described experience, TAVR in unicuspid valve has not yet been described. A challenging case is described with TAVR in UAV using a Edwards Sapiens prosthesis via transapical approach. © 2016 Wiley Periodicals, Inc.     

Abnormal distortion of aortic corevalve bioprosthesis with suicide left ventricle,aortic insufficiency,and severe mitral regurgitation during transcatheter aortic valve replacement

We present a patient with critical degenerative aortic stenosis, mitral annular and aortomitral continuity calcification, and senile sigmoid septal hypertrophy who underwent transcatheter aortic valve replacement using the CoreValve bioprosthesis. Immediately after predilation of the aortic valve (18‐mm balloon), the patient developed severe hypotension and dynamic left ventricular outflow tract (LVOT) obstruction with systolic anterior motion of the anterior mitral leaflet, causing severe mitral regurgitation. After deployment of a 26‐mm bioprosthesis, a transesophageal echocardiogram and left ventriculogram showed that the frame of the bioprosthesis appeared distorted and underexpanded. On the mitral side of the aorta (side of the aortomitral curtain between 12:00 and 3:00, echo short axis view), we found moderate periprosthetic aortic insufficiency with worse mitral regurgitation. The left ventricle was small and hyperdynamic (ejection fraction >85%). The patient soon developed complete heart block, atrial fibrillation, and ventricular tachycardia. She was resuscitated with aggressive intravenous fluids, vasopressors, and an emergently placed atrioventricular sequential pacemaker. We postdilated the 26‐mm bioprosthesis with a 22‐mm Z‐Med balloon and subsequently with a 25‐mm balloon. Each balloon was inflated to its nominal volume and pressure and conformed the nitinol frame of the valve to the net circular shape and expected diameter. However, as soon as each balloon was deflated, the surrounding aortic root anatomy visibly recoiled and the frame returned to its smaller diameter with a distorted shape. A second 26‐mm CoreValve bioprosthesis was then deployed in a “valve‐in‐valve” configuration. Soon after, the patient's hemodynamics improved, her clinical condition stabilized, and she completely recovered. © 2016 Wiley Periodicals, Inc.     

Transcatheter mitral valve thrombosis: A case report and literature review

Transcatheter mitral valve replacement (TMVR) is an exciting alternative therapy for complex patients with mitral valve disease. Experience with TMVR is new and there is a lot yet to discover about their durability, long-term outcomes, and complications including mitral transcatheter heart valve (THV) thrombosis. Many factors have been speculated to increased risk of THV thrombosis. Here, we report a case of a 72-year-old woman who developed mitral THV thrombosis after undergoing TMVR for severe mitral regurgitation with mitral annular calcification. We reviewed 42 TMVR papers with 1,484 patients, including 60 with mitral THV thrombosis. We discussed the most common strategies used for mitral THV thromboprophylaxis and treatment.     

Wolf in wolf's clothing--a case of prosthetic aortic valve thrombosis presenting as an acute coronary syndrome

Mechanical prosthetic valve thrombosis (PVT) is a potentially life threatening event that occurs with an incidence of 0.2% per patient year following aortic valve replacement [Lengyel M, Fuster V, Keltal M, et al. Guidelines for management of left-sided prosthetic valve thrombosis: a role for thrombolytic therapy. J Am Coll Cardiol 1997;30:1521-6]. We present the case of a middle-aged man with thrombosis of his aortic valve prosthesis mimicking an acute coronary syndrome. The patient received thrombolytic therapy with subsequent embolism of thrombotic debris to the leg.     

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.