Valve-in-Valve-in-Valve Transcatheter Aortic Valve Implantation to Treat a Degenerated Surgical Bioprosthesis in a Subaortic Position

Transcatheter aortic valve implantation for aortic stenosis has evolved as an alternative treatment for patients who are at high or excessive surgical risk. We report the case of an 84-year-old man with a degenerated surgically implanted valve in a subaortic position (9 mm below the native annulus) who underwent “valve-in-valve” transcatheter aortic valve implantation with use of a Medtronic CoreValve system. We planned to deploy the CoreValve at a conventional depth in the left ventricular outflow tract; we realized that this might result in paravalvular regurgitation, but it would also afford a “deep” landing site for a second valve, if necessary. Ultimately, we implanted a second CoreValve deep in the left ventricular outflow tract to seal a paravalvular leak. The frame of the first valve—positioned at the conventional depth—enabled secure anchoring of the second valve in a deeper position, which in turn effected successful treatment of the failing subaortic surgical prosthesis without paravalvular regurgitation.Key words: Aortic valve insufficiency/surgery, bioprosthesis, heart valve prosthesis implantation/instrumentation/methods, intention-to-treat analysis, reoperation/methods, risk assessment, treatment outcomeTranscatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for the treatment of aortic stenosis in patients who are at high or excessive operative risk.¹ It has been shown that implanting a transcatheter valve within a failing surgical valve (“valve-in-valve”) is safe and effective.² However, the feasibility of this intervention for failing valves in subaortic position has not been reported. The implantation of a self-expandable transcatheter valve at a deep level in the left ventricular outflow tract (LVOT) (with inflow portion >8 mm below the noncoronary cusp) could expectedly be associated with an increased risk of paravalvular regurgitation, valve dislodgment, or both, because of insecure anchoring of the prosthesis in the lower anatomic structures of the LVOT.³ We report the case of a patient in whom we implanted 2 CoreValve® devices (Medtronic, Inc.; Minneapolis, Minn), to safely replace a failing surgical bioprosthesis in a subaortic position.     

Cerebral Protection against Left Ventricular Thrombus during Transcatheter Aortic Valve Replacement in a Patient with Critical Aortic Stenosis

Transcatheter aortic valve replacement is an increasingly common treatment of critical aortic stenosis. Many aortic stenosis patients have concomitant left ventricular dysfunction, which can instigate the formation of thrombus resistant to anticoagulation. Recent trials evaluating transcatheter aortic valve replacement have excluded patients with left ventricular thrombus. We present a case in which an 86-year-old man with known left ventricular thrombus underwent successful transcatheter aortic valve replacement under cerebral protection.Key words: Aortic valve stenosis/therapy, cerebral infarction/etiology, embolic protection devices, heart valve prosthesis implantation, intracranial embolism/prevention & control, stroke/etiology, thrombus, left ventricularTranscatheter aortic valve replacement (TAVR) has given hope to patients with surgically inoperable critical aortic stenosis.^1,2 However, the enthusiasm generated by this emerging technology has been tempered by the incidence of both silent and clinically apparent cerebral vascular accidents.^2–4 These events can be either atheroembolic (originating from manipulation of the TAVR sheath in a diseased ascending aorta) or thromboembolic (originating from intracardiac chambers or from the aortic valve itself). The presence of left ventricular (LV) thrombus has been shown to be responsible for up to 20% of cardioembolic events in a clinical setting.^5,6 According to professional societies, LV thrombus is a contraindication for TAVR; and such thrombus has been an exclusion criterion in clinical trials.^7–9 However, a minority of aortic stenosis patients in need of transcatheter valve therapy present with intraventricular thrombus that does not respond to anticoagulation and therefore poses a challenge to the clinician. Evidence to support the optimal treatment of these patients is lacking. We present a case of TAVR in which we used cerebral protection in treating a surgically inoperable patient who had an LV thrombus.     

Valve‐in‐valve using an Edwards Sapien XT into a JenaValve in a patient with a low originating left coronary artery and a heavily calcified aorta

Coronary obstruction during transcatheter aortic valve implantation is a potentially life‐threatening complication. Most of the widely used transcatheter heart valves require a certain distance between the basal aortic annular plane and the origins of the coronary arteries. We report the case of a successful valve‐in‐valve procedure with an Edwards SAPIEN XT valve into a JenaValve as a bail‐out procedure in a patient with a low originating left coronary artery and a heavily calcified aorta. © 2015 Wiley Periodicals, Inc.     

Update on Transcatheter Aortic Valve Implantation

Aortic stenosis affects a significant number of patients worldwide, and carries a dismal prognosis once symptoms develop. Unfortunately, a large number of patients present a prohibitive risk for surgical aortic valve replacement. Therefore, transcatheter aortic valve implantation has emerged as a promising technology for providing treatment to this group of patients. Currently available valves include the balloon-expandable Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA), which is usually implanted via a transfemoral or transapical approach, and the self-expanding CoreValve ReValving system (Medtronic, Minneapolis, MN), which uses only the transfemoral route. Early experience with the procedure performed on a compassionate-use basis was encouraging, and led to a number of first-in-man and feasibility studies. These trials demonstrated the safety and efficacy of valve implantation and led to CE (European Conformity) mark approval of both valves in Europe. Use of the SAPIEN valve in the United States is limited to the recently completed PARTNER (Placement of Aortic Transcatheter Valve) randomized trial comparing transcatheter and surgical aortic valve replacement in high-risk patients, and its post-trial registry. The CoreValve is not yet available in the United States. With improved device technology, better understanding of patient selection and pre- and periprocedural imaging, and greater procedural experience, widespread diffusion of transcatheter aortic valve implantation is expected.     

Use of the SAPIEN 3 Transcatheter Heart Valve in High-Risk Scenarios

The transcatheter aortic valve replacement procedure is used in patients with aortic stenosis. Transcatheter aortic valve replacement devices are quite versatile; thus, they are increasingly being used for nonaortic applications, such as tricuspid valve-in-valve implantation. This case series describes a transcatheter aortic valve replacement procedure in 4 patients with anatomic challenges (eg, aortic tortuosity, high valvular calcium burden, highly calcified bicuspid valve, low coronary artery takeoff, left main coronary artery occlusion, and large aortic annulus) and a fifth patient who had a failed tricuspid bioprosthesis and underwent a tricuspid valve-in-valve implantation with the Edwards SAPIEN 3 transcatheter heart valve (Edwards Lifesciences). All procedures required adjustments to the standard protocol, and each procedure was successful. The critical, technical adjustments in the deployment technique and preprocedural planning of the procedures are detailed to provide a road map for other cardiologists who encounter similar challenges.     

Replacement of a Björk-Shiley Delrin aortic valve still functioning after 25 years

We report the case of a patient who had undergone implantation of a Björk-Shiley Delrin valve in the aortic position 25 years earlier and who now presented with severe mitral stenosis. The patient underwent mitral valve replacement and aortic valve re-replacement. We review the justification for prophylactic replacement of Björk-Shiley Delrin heart valves.Key words: Aortic valve, delrin, heart valve prosthesis/history, human, middle aged, mitral valve, prosthesis design/history, reoperation, risk factors, time factorsSince the 1st clinical use of the Björk-Shiley Delrin (BSD) prosthetic heart valve in 1969, follow-up studies have shown that such valves continue to function satisfactorily for up to 27 years. It has been estimated that approximately 24,000 BSD heart valves were implanted from 1969 through 1981 and that 7,000 of the patients who received those valves were alive as of January 1996.¹     

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.     

Quantitative myocardial blush grade: Prepped for a core lab standardization

Treatment of aortic stenosis remains challenging in older individuals, as their perioperative mortality for open heart surgery is increased due to comorbidities. Transcatheter aortic valve implantation using the CoreValve ReValving System (Medtronic, Minneapolis, USA) and the Edwards SAPIEN transcatheter heart valve (THV; Edwards Lifescience, Irvine, California, USA) represents an alternative to conventional valve replacement in elderly patients that have a high risk for conventional surgery. This article summarizes the evidence‐base from recent clinical trials. The early results of these landmark studies suggest that transcatheter aortic valve implantation with either one of the prosthesis is feasible, safe, improves hemodynamics and, therefore, might be an alternative to conventional aortic valve replacement in very high‐risk patients. However, all of the available transcatheter heart valves have certain disadvantages, limiting their use in daily clinical practice. The process of decision making, which valve to use and which access route to choose is illustrated in this article through clinical case scenarios. Additionally, the lessons learned thus far from the European perspective and the potential impact on the future use in the US are discussed. Despite of the progress in this field, we are still lacking an optimal transcatheter heart valve. Once it is available, we can take the plunge to compare transcatheter valve implantation with convention surgery in severe aortic stenosis! © 2009 Wiley‐Liss, Inc.     

Pseudoaneurysm in the Left Ventricular Outflow Tract after Prosthetic Aortic Valve Implantation: Evaluation upon Multidetector-Row Computed Tomography

The high accuracy of multidetector-row computed tomography (MDCT) in evaluating prosthetic valve disorders has been confirmed. This, we believe, is the 1st report of the use of MDCT to detect and evaluate left ventricular outflow tract (LVOT) pseudoaneurysms in patients who have undergone aortic valve replacement with prosthetic valves. We used MDCT to scan 21 such patients, 3 of whom had a small pseudoaneurysm in the LVOT. Each pseudoaneurysm projected away from the LVOT and had a narrow neck that was located just below the sewing ring of the prosthetic aortic valve. One pseudoaneurysm was not thrombotic, 1 was partially thrombotic, and 1 was completely thrombotic. One of these had gone undetected earlier on transthoracic echocardiography.We consider MDCT to be superior to echocardiography in the detection of LVOT pseudoaneurysms in patients who have undergone aortic valve replacement with prosthetic valves. We publicize our results in the hope that larger studies will be undertaken in order to investigate the prevalence and clinical implications of our findings.Key words: Aneurysm, false/etiology/radiography; aortic valve/radiography; blood coagulation disorders/etiology; echocardiography; heart valve diseases/complications/radiography; heart valve prosthesis implantation; imaging, three-dimensional; radiographic image interpretation, computer-assisted; sensitivity and specificity; thrombosis/radiography; tomography, X-ray computed/methods; ventricular outflow obstruction/etiology/radiographyAortic valve replacement is the ultimate treatment for severe aortic valve diseases.¹ Regular follow-up with cross-sectional imaging and early intervention to treat valvular disorders are crucial toward improving survival rates after valve replacement.¹ Disorders include thrombus formation,^2,3 pannus formation,^4,5 valve dysfunction,^3,5,6 suture dehiscence (paravalvular leakage),⁵ and left ventricular outflow tract (LVOT) pseudoaneurysm.^7–9 Most prosthetic valve disorders can be accurately diagnosed with the use of multidetector-row computed tomography (MDCT),^2–6 and with better accuracy than that of transthoracic echocardiography.⁵ However, MDCT findings of LVOT pseudoaneurysm have not, to our knowledge, been reported heretofore in the medical literature. We present our MDCT findings of LVOT pseudoaneurysm, drawn from our studies of patients in a 1,500-bed tertiary-referral medical center. Clinical implications of the imaging results will also be discussed.     

Transcatheter Aortic Valve Implantation Despite Challenging Vascular Access

We describe transcatheter aortic valve implantation in a patient who had severe peripheral artery disease. The patient''s vascular condition required additional preliminary peripheral intervention to enable adequate vascular access.A 78-year-old man with severe aortic stenosis, substantial comorbidities, and severe heart failure symptoms was referred for aortic valve replacement. The patient''s 20-mm aortic annulus necessitated the use of a 23-mm Edwards Sapien valve inserted through a 22F sheath, which itself needed a vessel diameter of at least 7 mm for percutaneous delivery. The left common femoral artery was selected for valve delivery. The left iliac artery and infrarenal aorta underwent extensive intervention to achieve an intraluminal diameter larger than 7 mm. After aortic valvuloplasty, valve deployment was successful, and the transaortic gradient decreased from 40 mmHg to less than 5 mmHg. The patient was discharged from the hospital 4 days postoperatively. We conclude that transcatheter aortic valve implantation can be successfully performed in patients with obstructed vascular access, including stenosis of the infrarenal aorta and the subclavian and coronary arteries.     

Transfemoral Edwards SAPIEN Aortic Valve Implantation Through Aortofemoral Endograft

We present the case of an 86-year-old woman with an aortobifemoral endograft and porcelain aorta who underwent transfemoral transcatheter aortic valve implantation (TAVI). A femoral cutdown was performed to the left limb of the endograft, and the needle puncture into the graft required sequential incisions and dilation to allow access of the 18F Edwards SAPIEN expandable eSheath (Edwards Lifesciences, Irvine, CA). A 26-mm Edwards SAPIEN transcatheter aortic valve was then successfully deployed. The cutdown was closed and hemostasis was achieved without any iatrogenic narrowing of the graft. Transfemoral TAVI through surgical cutdown with dilation of a femoral endograft is safe and feasible.     

Bioprosthetic Valve Leaflet Displacement During Valve-in-Valve Intervention: An Ex Vivo Bench Study

ObjectivesThe aim of this study was to examine the effect of different transcatheter heart valves (THVs) on valve leaflet displacement when deployed within bioprosthetic surgical valves and, thereby, risk for coronary obstruction.BackgroundCoronary obstruction is a potentially devastating complication during valve-in-valve (ViV) transcatheter aortic valve replacement. Strategies such as provisional stenting and intentional bioprosthetic valve leaflet laceration have been developed to mitigate this risk. Alternatively, the use of a THV that retracts the bioprosthetic leaflet away from the coronary ostium may prevent coronary obstruction.MethodsA 25-mm J-Valve, a 26-mm Evolut Pro, and a 23-mm JenaValve were implanted into both a 25-mm Trifecta surgical valve and a 25-mm Mitroflow surgical valve. A 23-mm and a 26-mm SAPIEN 3 were deployed into the Trifecta and Mitroflow, respectively. Displacement of the surgical valve leaflets (retraction vs. expansion) was measured with implantation of each THV by measuring displacement angle and maximal displacement distance.ResultsWithin both the Trifecta and Mitroflow valves, implantation of the J-Valve and JenaValve resulted in retraction of the surgical valve leaflets, and placement of the Evolut Pro and SAPIEN 3 resulted in tubular expansion of the surgical valve leaflets. There were significant differences in displacement angles and distances between both the J-Valve and JenaValve and the SAPIEN 3 and Evolut Pro (p < 0.0001).ConclusionsViV implantation with new-generation THVs that directly interact with bioprosthetic valve leaflets results in surgical valve leaflet retraction. This might mitigate the risk for coronary obstruction in selected cases of ViV transcatheter aortic valve replacement and also facilitate coronary reaccess after ViV TAVR.     

Coronary Ostial Stenosis after Aortic Valve Replacement: Successful Treatment of 2 Patients with Drug-Eluting Stents

Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention.Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option.Key words: Angioplasty, transluminal, percutaneous coronary; aortic valve/surgery; cardiac surgical procedures/adverse effects; coronary artery disease/etiology/prevention & control; coronary stenosis/diagnosis/etiology/therapy; heart valve prosthesis implantation/adverse effects; iatrogenic disease/prevention & control; perfusion/adverse effects/instrumentation; postoperative complications/therapy; treatment outcomeCoronary ostial stenosis is a rare but potentially serious postoperative sequela of aortic valve replacement (AVR). Ostial stenosis can occur in the left main coronary artery (LMCA) or in the right coronary artery (RCA). The condition, first described by Roberts and Morrow in 1967,¹ is believed to occur after 1% to 5% of AVR procedures.^2–7 No underlying cause has been determined. The clinical symptoms of coronary ostial stenosis are usually severe and can appear from 1 to 6 months postoperatively.^8,9 Although the typical treatment is coronary artery bypass grafting (CABG), patients have been successfully treated by means of percutaneous coronary intervention (PCI).^10–15 Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after AVR, discuss their PCI treatment, and offer our conclusion regarding the feasibility of PCI in the treatment of coronary ostial stenosis.     

Aortic Valve Noncoronary Cusp Thrombosis after Implantation of a Nonpulsatile, Continuous-Flow Pump

Different institutions have different strategies for managing both native and prosthetic aortic valves in recipients of left ventricular assist devices (LVADs). Anticoagulation protocols and pump-flow algorithms remain nonstandardized. We describe our institutional experience with thrombotic complications and our evolving approach to this important clinical problem. We report the cases of 4 HeartMate II LVAD recipients in whom, despite an anticoagulative regimen, thrombus formed on the noncoronary cusp of the aortic valve. The management of the closed aortic valve in LVAD-supported patients remains problematic.Key words: Aortic valve/pathology, heart-assist devices/adverse effects, thrombosis, ventricular dysfunction, leftThe first implantation of the current clinically approved HeartMate® II Left Ventricular Assist System (Thoratec Corporation; Pleasanton, Calif) was performed at our center in November 2003.¹ Currently, the HeartMate II is the world''s most widely used implantable left ventricular assist device (LVAD), both for bridging to transplantation and for destination therapy, and our center has had one of the largest single-center experiences with this pump to date. As of August 2012, we had performed 318 implantations of this device. The HeartMate II LVAD frequently works in parallel with the natural heart; as a result, in this operational mode, the aortic valve usually remains in a closed position, and the resulting stagnation of flow in the aortic root may favor thrombus formation. Although the HeartMate II yields better overall results and fewer complications than do pulsatile LVADs,^2–4 thrombus on the noncoronary cusp of the aortic valve (which has never occurred in our experience with pulsatile pumps) has occurred in 4 of our patients who have had the HeartMate II implanted. We describe our experience with this unusual complication and its management.     

Surgical Repair of Supravalvular Aortic Stenosis with Use of Brom's Technique: Short-Term Results in 9 Children

There are few published reports of the results of supravalvular aortic stenosis correction with the use of Brom''s 3-patch technique. Herein, we report our use of this procedure and the short-term results therefrom.From 2002 through 2007, 9 children underwent surgical correction of localized supravalvular aortic stenosis at our hospital. The patients ranged in age from 5 to 14 years, and 8 had Williams syndrome. All operations were performed by the same surgical team.No clinically significant associated cardiac anomalies were encountered. Each aortic repair involved the use of pericardium, Dacron, or both. One patient had an uncorrected right coronary artery obstruction and died postoperatively of refractory supraventricular tachycardia. In all 8 patients who survived, postoperative transaortic blood pressure gradients were improved (range, 0–16 mmHg), and no repeat operations were needed after 6 to 55 months'' follow-up.We consider Brom''s technique to be safe in the repair of supravalvular aortic stenosis. In our limited series, it produced effective anatomic restoration, with good short-term and potentially good long-term results.Key words: Aortic stenosis, supravalvular/complications/mortality/surgery; aortic valve stenosis/physiopathology/surgery; cardiac surgical procedures/methods; child; disease-free survival; heart defects, congenital/complications; survival analysis; treatment outcome; vascular surgical procedures/methods; Williams syndrome/physiopathologySupravalvular aortic stenosis (SVAS) is an uncommon but well-characterized congenital narrowing of the ascending aorta above the level of the aortic valve (Fig. 1).¹ Most often, the narrowing is localized just above or at the most superior level of the attachments of the valve commissures, in association with some dilation of the sinuses of Valsalva and absence of poststenotic dilation. The aorta then looks like an hourglass. Less often, the narrowing extends diffusely throughout the ascending aorta and sometimes extends into the arch and the origins of the brachiocephalic artery. Supravalvular aortic stenosis occurs in 3 forms: sporadic; as part of Williams syndrome; or in a familial form that is transmitted as an autosomal dominant trait.^2–4 The origin of SVAS is strongly suspected to depend on a quantitative reduction in elastin during development.^2,5–6Open in a separate windowFig. 1 A) Preoperative catheterization image of a patient with supravalvular aortic stenosis shows a narrowed supravalvular diameter with minimal aortic regurgitation. B) Postoperative image in the same patient shows a regular supravalvular diameter and a competent aortic valve.Since the 1st successful repair in 1956, various surgical techniques for the relief of SVAS have been developed.⁴ Extended aortoplasty that enlarges the affected structures, as reported by Doty and colleagues,⁷ is most commonly used to treat the anomaly. Because this technique reconstructs only the right and noncoronary sinuses, the left sinus might still exhibit substantially distorted anatomy, with the risk of ischemia secondary to limited inflow into the left coronary artery.^3,8 Steinberg and associates⁹ reported the cases of 3 patients in whom a double patch was used in order to improve the geometry of the aortic sinuses. Subsequently, Brom introduced symmetric aortoplasty that enabled the enlargement of all 3 sinuses with the use of a 3-patch technique.^3,8Supravalvular aortic stenosis is a rare disease, and most of the reported surgical series have been small. In view of the few reports on the use of Brom''s technique for SVAS repair, we report here our experience with the first 9 such corrections that were performed at the Hospital de Pediatría, CMNO IMSS, Guadalajara, Jalisco, México.     

Quadricuspid Aortic Valve without Severe Dysfunction despite Advanced Age

We report the case of a 75-year-old woman who presented with stable angina and with a quadricuspid aortic valve, which consisted of 4 equal-sized leaflets that were diagnosed incidentally upon coronary angiography. Despite the patient''s advanced age, the abnormal valve was functioning almost normally.Key words: Aged, aortic valve/anomalies, coronary angiography, heart defects, congenital/diagnosis, heart valve diseasesSince the 1st case of quadricuspid aortic valve was published in 1969,¹ the total number of reported cases has reached approximately 200.² The diagnosis—more frequent in men—is commonly made between the 5th and 6th decades of life.^1,2 If valve replacement is needed (due mostly to severe aortic insufficiency), that too occurs most often in the 5th or 6th decade.³ However, we report a case in which a woman''s quadricuspid aortic valve was diagnosed in her 8th decade and did not result in significant valvular dysfunction, despite her advanced age.     

Ischemic colitis after transcatheter aortic valve implantation

Transcatheter aortic valve implantation is a novel therapeutic approach for high‐risk patients with severe symptomatic aortic stenosis. The success rate of this new procedure is high; however, it is associated with issues such as vascular access site complications and embolization related to the advancement of a large bore delivery catheter through the femoral and iliac arteries and aortic arch. Using the Edwards SAPIEN transcatheter heart valve, we describe a case of transfemoral catheter aortic valve implantation complicated by a mobile mass attached to the valve, probable due to atherosclerotic plaque from the aorta. Shortly thereafter, the patient presented with ischemic colitis and subsequently died. © 2012 Wiley Periodicals, Inc.     

Optimized Implantation Height of the Edwards SAPIEN 3 Valve to Minimize Pacemaker Implantation After TAVI

Aim

The transcatheter aortic valve SAPIEN 3 aims at reducing paravalvular leakage (PVL). The new design with outer sealing cuff may increase the risk of permanent pacemaker implantation (PPM). The aim of our study was to evaluate the optimal implantation height of the SAPIEN 3.

Methods and Results

We analysed the correlation between the implantation height of the valve and the need for PPM in 131 patients. The PPM rate for the entire group after TAVI was 18% (n = 24). In patients with a marker distance <2 mm (“low implantation”), the PPM rate was 32%, whereas in patients with a distance ≥2 mm (“high implantation”), the rate was only 4.7% (OR of 0.1 (0.03–0.37, P < 0.001)).

Conclusion

The risk of periprocedural PPM with the Edwards SAPIEN 3 depends on implantation height; it is increased when using conventional implantation techniques. This risk can be minimized below 5% PPM by choosing a higher implantation technique with the central marker 2 mm or more over the annulus plane.

     

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.     

Early Failure Secondary to Noncoronary Leaflet Prolapse in a Stentless Aortic Bioprosthesis

Structural degeneration is an important long-term disadvantage of biologic prostheses. However, early failure of these prostheses is uncommon and is usually caused by rapid calcification. We report the successful management of a rare case of early failure of a stentless aortic bioprosthesis (within 4 months of implantation). The patient presented with severe noncalcific aortic regurgitation secondary to prolapse of the noncoronary leaflet. In consideration of the acute nature of failure in this new-generation bioprosthesis and its unclear cause, we believe that this report, albeit of a single case, warrants some attention.Key words: Aortic valve insufficiency/surgery, bioprosthesis/failure, complication, disease progression, heart valve prosthesis/failure, reoperationAortic valve replacement using stentless biological prostheses offers the benefits of good hemodynamics,¹ without the requirement of prolonged anticoagulation.² Although their major drawback—structural degeneration in the long term—is well documented,³ bioprostheses rarely fail early, and, when they do, rapid calcification of the valve leaflets is the usual cause.⁴ We report the successful management of a rare case of early failure of a stentless aortic bioprosthesis within 4 months of implantation. The patient presented with severe noncalcific aortic regurgitation secondary to prolapse of the noncoronary leaflet.