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.     

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.     

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.     

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.     

First‐in‐human valve‐in‐valve implantation of a 20 mm balloon expandable transcatheter heart valve

An 86‐year‐old lady with recurrent admissions for heart failure due to a severely regurgitant aortic bioprosthesis (SJM Epic 19 mm) was not a candidate for re‐operation due to age and frailty. Her small ilio‐femoral arteries precluded a transfemoral transcatheter valve‐in‐valve (VIV) approach. The small internal diameter of her bioprosthesis (16 mm) forbids the implantation of the smallest available transapical transcatheter heart valve (THV). We, therefore, decided to perform a first‐in‐human transapical aortic VIV implantation using a 20 mm balloon expandable THV and a transfemoral delivery system. The procedure was successfully performed under general anesthesia, without any contrast dye and under fluoroscopy as well as transesophageal echocardiography guidance. The post‐procedural transvalvular gradient was 15 mm Hg (pre‐procedural 14 mm Hg). At 30‐day follow‐up, the lady was living independently at home without shortness of breath during her daily activities. If redo‐surgery for prosthetic regurgitation is not an option, VIV implantation in very small surgical bioprosthesis is feasible and leads to acceptable hemodynamics and clinical improvement.© 2012 Wiley Periodicals, Inc.     

Balloon valuloplasty prior to transcatheter valve‐in‐valve implantation in a degenerated mitroflow aortic bioprosthesis

Transcatheter valve‐in‐valve implantation is an emerging treatment option for high‐risk patients with failing aortic bioprostheses. The presence of the prosthesis stents is thought to prevent coronary artery obstruction, a known complication of transcatheter aortic valve implantation in the native aortic valve. The Sorin Mitroflow aortic bioprosthesis (Sorin Group, Saluggia, Italy) has a particular design in that the pericardial leaflets are mounted outside the valve stent. As a consequence, the pericardial leaflets of this prosthesis may be displaced well away from the stents during the deployment of transcatheter valves. This might explain why both the cases of coronary occlusion following valve‐in‐valve implantation reported to date occurred in patients with a malfunctioning Mitroflow bioprosthesis. We describe a patient with a malfunctioning 25 mm Mitroflow bioprosthesis successfully treated by percutaneous transcatheter valve‐in‐valve implantation, and discuss the role that balloon aortic valvuloplasty plays in the performance of this delicate procedure. © 2012 Wiley Periodicals, Inc.     

“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.     

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.     

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.     

First transcatheter valve‐in‐valve implantation in an apicoaortic conduit

Apicoaortic conduit surgery is an option for treating severe aortic stenosis. The implanted conduit valve may eventually fail and require replacement; this is usually performed by repeat surgery. Treating the conduit valve with a standard transcatheter heart valve is an option that has become feasible in recent years. We describe a case of a failed 23 mm CE bioprosthesis that was successfully treated with a 23 mm Sapien XT valve as a valve‐in‐valve procedure. © 2017 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.     

Simultaneous transcatheter pulmonary and tricuspid valve‐in‐valve implantation for the treatment of failing pulmonary and tricuspid bioprostheses

We report a case of a patient with a history of bioprosthetic pulmonary and tricuspid valve replacement who developed significant stenosis and regurgitation of the bioprosthetic valves. Due to multiple comorbidities, he was deemed high risk for redo‐valve replacement surgery. He subsequently underwent percutaneous transcatheter pulmonary and tricuspid valve‐in‐valve procedure at the same setting. This is the first of such that is reported in the literature. © 2015 Wiley Periodicals, Inc.     

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.     

The valve‐in‐valve technique: Transcatheter treatment of aortic bioprothesis malposition

Percutaneous aortic valve replacement is an emerging alternative to palliative medical therapy for nonsurgical patients with severe aortic valve stenosis. The impossibility of repositioning of the current transcatheter prosthesis in case of suboptimal placement is the main limit of these devices. Here, we report on a case of an 84‐year‐old woman successfully treated with implantation of two 18‐Fr CoreValve® prosthesis (CoreValve®, Irvine, California), because of the suboptimal deployment of the first one, analyzing the procedural technique and the immediate and short‐term clinical and hemodynamic results. © 2009 Wiley‐Liss, Inc.     

Valve‐in‐valve transcatheter aortic valve implantation with CoreValve/Evolut R© for degenerated small versus bigger bioprostheses

Objectives

We present our single center experience with Medtronic CoreValve and Evolut R regarding procedural outcome and 3 years follow‐up in patients with degenerated bioprostheses.

Methods

From 1645 patients who underwent transfemoral TAVI at our institution between February 2009 and December 2016, 37 patients with degenerated bioprosthesis were treated with Medtronic CoreValve/Evolut R. All data concerning baseline characteristic, procedural outcomes and follow‐up were entered into a dedicated database.

Results

Mean age was 83.9 ± 4.4 years and patients showed an average logistic EuroSCORE of 33.2 ± 16.7%. Successful ViV deployment was achieved in all cases, a permanent pacemaker was implanted in 16.2%, no periinterventional stroke and no coronary obstruction occurred. Mortality at 30 days was 2.7%, at 1‐year follow‐up 5.7% and at three years 13.5%. Depending on bioprosthesis size <23 mm versus ≥23 mm echocardiographic mean gradients post implantation were significantly higher in the smaller bioprostheses, 22.8 mmHg ± 9.4 mmHg versus 15.1 ± 7.1, P = 0.013.

Conclusion

ViV‐TAVI with CoreValve/R is demonstrated to be safe and effective in terms of no coronary obstruction and very low mortality up to 3 years despite slightly higher mean transprosthetic gradients especially in very small bioprostheses.

     

Transcatheter aortic valve implantation

Background : Transcatheter aortic valve implantation (TAVI) is a rapidly evolving strategy for therapy of aortic stenosis. We describe the effect of the learning curve from the first 270 high‐risk patients in Vancouver, Canada. Methods : Patients underwent TAVI by transfemoral (63%) or transapical (37%) routes using balloon expandable valves. The experience was divided into the first half (FH, patients 1–135) and second half (SH, patients 136–270). Results : The mean age was 83.2 ± 8 years (FH 83 ± 12 vs. SH 81 ± 7 years, P = 0.12). The mean Society of Thoracic Surgeons Score (STS) was 9.5% ± 5.2%‐ FH 10.5 vs. SH 8.5% (P = 0.01). The overall procedural success rate in the FH was 92.6%, improving to 97.8% in the SH (P = 0.05). The transfemoral procedural success improved—FH 89.3% to SH 98.8% (P = 0.01). The transapical procedural success remained high—FH 98.0% to SH 96.1% (P = 0.53). The overall 30‐day mortality was 9.6%, improving from FH 13.3% to SH 5.9% (P = 0.04). In the transfemoral cases, 30‐day mortality decreased by 56% [10.7–4.7%, P = 0.14], and similarly in transapical cases [17.6–7.8%, P = 0.14]. In‐hospital stroke occurred in 3.3% (FH 3.7% vs. SH 2.9%, P = 0.74). The overall need for a new permanent pacemaker was 5.9% (FH 5.9% vs. SH 5.9%, P = 1). The overall major vascular injury rate was 6.7% (FH 8.1% vs. SH 5.2%, P = 0.33). The overall incidence of coronary vessel occlusion was 1.1% (FH 1.5 % vs. SH 0.7%, P = 0.56). Device embolization or failure to cross the valve was rare and largely seen in the FH only. Procedural experience (>135 procedures) was an independent predictor of 30‐day survival (HR: 6.7, 95% CI: 1.2–18.1, P = 0.03). Conclusion : TAVI outcomes improve with experience and device development. While overall complication rates are low, scope remains to further reduce procedural adverse events.© 2011 Wiley Periodicals, Inc.     

Transcatheter tricuspid valve‐in‐valve replacement: Making it simpler

Transcatheter tricuspid valve‐in‐valve replacement (TTVR) represents an attractive therapeutic option in very high surgical risk patients with degenerated tricuspid bioprostheses. However, the procedural management of these patients might be challenging due to their comorbidities, long lasting heart valve disease and the presence of left‐sided mechanical prostheses. Thus, a more “minimally disruptive” procedure would have several potential benefits in such a frail population. We present the cases of four patients admitted for congestive heart failure due to severe degeneration of their tricuspid bioprostheses who were treated with a minimalist TTVR. The protocol combined continuation of the oral anticoagulant treatment with no bridging therapy, the use of a single venous access with local anesthesia, rapid pacing via the stiff right ventricular wire, and transthoracic echocardiographic guidance and assessment, with no need for contrast injection. Our protocol aims at simplifying the TTVR procedure and might be a useful tool to avoid procedural complications and reduce hospital stay.