Transcatheter aortic valve implantation in a patient with mechanical mitral prosthesis: A lesson learned from an intraventricular clash

We hereby present the case of a patient with severe aortic stenosis who underwent in her previous medical history a mitral valve replacement with a mechanical valve (Omnicarbon 27), and progressively developed a severe aortic stenosis. This patient was judged inoperable and then scheduled for CoreValve Revalving System implantation. Despite a good positioning of the CoreValve, an acute, severe mitral regurgitation developed soon after implantation as a consequence of the impaired movement of the mitral prosthesis leaflet. A condition of cardiogenic shock quickly developed. A good mitral prosthesis function was restored disengaging the CoreValve from the aortic annulus. After few months, the patients underwent successful Edwards‐Sapien valve implantation through the Corevalve. This case strongly demonstrates how much a careful evaluation of the features of the mitral prosthesis and patient anatomy is crucial to select which specific transcatheter bioprosthesis would better perform. © 2013 Wiley Periodicals, Inc.     

Multiple cerebral emboli following dislocation and retraction of a partially deployed CoreValve prosthesis during transcatheter aortic valve implantation

Transcatheter aortic valve implantation for patients with severe aortic stenosis at a high‐operative risk has been demonstrated to improve mortality compared to standard medical therapy. Registry data and the PARTNER trial have shown a significant risk of stroke (3–5%) following the procedure. Studies using cerebral diffusion‐weighted magnetic resonance imaging have suggested the mechanism of stroke to be multiple small embolic infarcts, possibly from aortic atheroma dislodged during the movement of the valve and its apparatus around the thoracic aorta. The incidence of these infarcts is higher than clinically apparent. The Medtronic CoreValve (Medtronic, Minneapolis, Minnesota) prosthesis is a self‐expanding nitinol frame with porcine valve, whose deployment is achieved by the retraction of the delivery catheter. Potential complications of this method include valve mal‐positioning and dislocation. The partially deployed valve may then be resheathed following retraction back into the descending aorta and subsequently redeployed. We present two such cases with evidence of both “silent” and clinically evident cerebral infarction. © 2013 Wiley Periodicals, Inc.     

Transcatheter aortic valve replacement

We report a new technique of the partially and sequentially gonflage of the transcatheter balloon valve, the so called dog bone shaped technique, which allowed us to approach the aortic root by inflating the valve balloon in two different times, stabilizing the heart and deplacing the valve. © 2010 Wiley‐Liss, Inc.     

Good outcome and valve function despite medtronic‐corevalve underexpansion

An 80‐year old nun with severe calcific aortic stenosis and a bicuspid aortic valve was referred for transcatheter aortic valve implantation. She was declined for conventional surgery on the basis of poor left ventricular function, frailty, and a logistic EuroSCORE of 29.66. A 29‐mm Medtronic‐Corevalve bioprosthesis was implanted by transfemoral route. The inflow portion of the stent frame was grossly underexpanded. However, aortic valve area at 1.3 cm² was more than satisfactory for a body surface area of 1.29 m² (indexed area 1.0 cm²/m², peak gradient 23, and mean 16 mmHg). There was an early sustained improvement in New York Heart Association (NYHA) status, and there was no change in valvular function at 2 year follow‐up. This case highlights that gross underexpansion of the Medtronic‐Corevalve stent frame is compatible with good bioprosthetic function and excellent symptomatic recovery. © 2010 Wiley‐Liss, Inc.     

Predictors of moderate‐to‐severe paravalvular aortic regurgitation immediately after corevalve implantation and the impact of postdilatation

Objective : To investigate the predictors of moderate‐to‐severe aortic regurgitation (AR≥2+) after CoreValve implantation and evaluate the feasibility and safety of postdilatation in reducing the degree of AR. Background : Although transcatheter aortic valve implantation is an alternative treatment for high surgical risk patients with severe aortic stenosis, post‐implantation paravalvular AR remains a complication. Methods : From July 2008 to July 2010, we enrolled 79 consecutive patients with severe aortic stenosis who underwent CoreValve implantation. Results : On univariable analysis, the predictors of AR≥2+ immediately after CoreValve implantation were: larger annulus size, low implantation, prosthesis mismatch, chronic renal insufficiency, a history of heart failure, and peripheral vascular disease. On multivariable analysis, the independent predictors of AR≥2+ were: larger annulus diameter (OR 1.78, 95%CI 1.25–2.55; P = 0.002), low implantation (OR 3.67, 95%CI 1.01–13.35, P = 0.05), and peripheral vascular disease (OR 3.54, 95%CI 1.19–10.56, P = 0.02). Post‐CoreValve implantation, AR ≥ 2 was seen in 40.5% (32/79). Twenty‐one patients underwent postdilatation with improvement in AR grade in the majority (17/21). Of the four patients who did not respond to postdilatation, two underwent valve‐in‐valve implantation. In one patient, the valve was pulled more proximally by the snare technique. The remaining 10 patients were treated conservatively. Conclusion : The appropriate strategy for treating patients with AR≥2+ depends on the causes and severity of AR post‐TAVI. This study suggests that we should carefully select the size of CoreValve prosthesis to prevent prosthesis mismatch, especially when implanted in larger annulus sizes. For valves implanted in the appropriate position, postdilatation appears effective in reducing the degree of AR. © 2011 Wiley‐Liss, Inc.     

Treatment of a degenerative stenosed CoreValve® aortic bioprosthesis by transcatheter valve‐in‐valve insertion

Background : Transcatheter aortic valve insertion (TAVI) is an emerging therapy in patients at high risk for open heart surgery. The long‐term durability of the bioprosthesis is unknown. This is the first report of a severely degeneratively stenosed 2nd generation 26 mm CoreValve^® aortic bioprosthesis which occurred five and a half years after TAVI. Methods and Results : A 92‐year‐old patient presented with decompensated heart failure NYHA class IV, pulmonary edema, and severe pulmonary hypertension. Echocardiography revealed critical AV‐stenosis due to heavily calcified bioprosthetic valve leaflets. Due to high surgical risk with an EuroSCORE of 64.97% and a STS‐mortality score of 27.0%, we decided to attempt a valve‐in‐valve insertion of a 3rd generation CoreValve^® prosthesis of the same size. Following the delicate retrograde passage of the calcified valve with a preformed stiff wire, balloon valvuloplasty of the severely stenosed CoreValve^® prosthesis under rapid right ventricular pacing was complicated by two balloon catheter ruptures. Insertion of the 3rd generation CoreValve^® prosthesis of the same size was quite complex but finally it was successfully completed. There was mild periprosthetic regurgitation and significant decrease in transaortic pressure without residual transvalvular gradient immediately after TAVI. Echocardiography and clinical follow‐up at 72 hr after TAVI confirmed excellent valve function with a decrease in systolic pulmonary artery pressure from 70 mm Hg to 35 mm Hg, increase in LV‐EF from 35% to 45%, and improvement of functional status from NYHA IV to NYHA II. The patient was discharged in good medical conditions at day eight. Conclusion : Degenerative stenosis of a CoreValve^® bioprothesis may be observed during long‐term follow‐up after successful TAVI for the treatment of severe aortic valve stenosis. A second valve‐in‐valve insertion appears feasible but may require particular interventional approaches. © 2011 Wiley Periodicals, Inc.     

Infective endocarditis following transcatheter aortic valve replacement—: Diagnostic and management challenges

Transcatheter aortic valve replacement (TAVR) can improve the symptoms and prognosis of patients with severe aortic stenosis who, due to a high expected operative risk, would not have otherwise been treated surgically. If these patients develop prosthetic valve endocarditis, their presentations may be atypical causing a delay in the diagnosis and treatment. The management is also complicated by their comorbidities, and surgical treatment may not be feasible leading to a significant morbidity and mortality. We describe a case of an 85‐year‐old man with TAVI prosthetic valve endocarditis successfully treated medically, discuss the challenges in the diagnosis and management of such patients, and review available literature on the incidence and outcome of the condition. © 2012 Wiley Periodicals, Inc.     

Transcatheter Aortic valve implantation in a patient with circulatory collapse,using the lucas® chest compression system

We describe a case of Transcatheter Aortic Valve Implantation (TAVI) using the LUCAS® Chest Compression System in an elderly high risk patient with severe aortic stenosis and heart failure. In this case, the patient developed severe aortic regurgitation following predilatation of the native aortic valve and automated cardiopulmonary resuscitation (A‐CPR) was initiated. The procedure was performed under ongoing A‐CPR for a total of 28 min. The patient was transferred to the intensive care unit and to a step down unit the following day. At follow‐up 30 days later, she showed no signs of neurologic or cardiac damage. This case report shows, that it is possible to perform the TAVI procedure under ongoing A‐CPR and that A‐CPR, judged by invasive blood pressures, was capable of maintaining a satisfactory perfusion pressure even with a damaged aortic valve. © 2013 Wiley Periodicals, Inc.     

Predictors for permanent pacing after transcatheter aortic valve implantation

Background : Transcatheter aortic valve implantation (TAVI) is a new treatment strategy for patients with symptomatic aortic stenosis who are high risk for traditional surgical aortic valve replacement. The incidence of conduction system abnormalities after the procedure is significant. We examine our experience with CoreValve TAVI focusing on electrocardiographic changes found pre‐, peri‐, and postintervention. Methods : During 2007–08 we undertook 33 cases utilizing the CoreValve revalving system (CoreValve, Paris, France). Assessment of ECGs, with particular reference to the PR and QRS duration, was made daily during each patient's hospital stay. Results : Patients were aged 81.7 ± 6.7 years and the majority were male (57%). Baseline cardiac rhythm was sinus (n = 28, 80%); atrial fibrillation (n = 6, 18%) or ventricular paced (n = 1, 3%). Following CoreValve implantation, prolongation of both the PR interval and QRS duration was seen. Preprocedural PR interval was 193.5 ± 38.7 ms and QRS interval preprocedure was 115.3 ± 24.8 ms. PR interval increased after the procedure by 23.5 ± 23.9 ms and peaked at day 4 with a mean increase of 66.1 ± 72.7 ms. QRS duration increased by a mean of 30.6 ± 26.1 ms postprocedure and remained stable thereafter during the remaining hospital stay. The need for PPM insertion was partially predicted by pre‐procedural QRS morphology: patients with pre‐existing right bundle branch block had an 83% chance of requiring a permanent pacemaker (P < 0.01 OR 28 95%CI 2.4–326.7); those with LBBB had a 33% chance of requiring a pacemaker (P = ns OR 2.3 95%CI 0.2–34.9). Patients undergoing the procedure later in our experience showed a decreased incidence of pacing (P = 0.046 OR 0.36 95% CI 0.07–1.82). Pre‐procedural annulus measurements also predicted the requirement for pacing with larger annulus sizes more likely to require a pacemaker (P = 0.044 OR 3.3 95% CI 0.63–17.6). The requirement for pacing was not predicted by age, baseline PR interval or gender. Requirement for pacing overall was 32% with an additional 13% having had a pacemaker inserted prior to the TAVI. Conclusion : CoreValve insertion was associated with an increase in PR interval and QRS duration. PR interval continued to rise during admission, peaking on Day 4 post procedure, making a prolonged period of monitoring highly desirable. There was a significant requirement for permanent pacing, which was predicted by pre‐procedural QRS morphology, annulus measurement, and the learning curve. © 2010 Wiley‐Liss, Inc.     

Trans catheter aortic valve implantation with core valve revalving system in uncoiled (horizontal) aorta. overcoming anatomical and technical challenges for successful deployment

Uncoiling of the aortic root (horizontal aorta) offers a considerable technical challenge in successful deployment of core valve prosthesis. The problem is compounded in the presence of significant calcification of the ascending aorta that limits the capability to control the tension on delivery catheter during device release and may lead to implant failure. Recognition of adverse anatomical features and use of proximal access sites such as subclavian artery are likely to attenuate the degree of technical difficulty in these cases. Familiarity and facility with retrieval techniques using a snare catheter is desirable in cases of implant failure. © 2011 Wiley Periodicals, Inc.     

Bailout perventricular pulmonary valve implantation following failed percutaneous attempt using the Edwards Sapien transcatheter heart valve

Percutaneous pulmonary valve implantation has emerged as an attractive and less invasive alternative to open‐heart surgery. Nevertheless, major technical challenges and procedural complications may still occur. We report a 44‐year‐old woman with severe dextroscoliosis, and history of Tetralogy of Fallot repair, who underwent an attempt at percutaneous implantation of a 23‐mm Edwards SAPIEN transcatheter heart valve (THV) for recurrent stenosis of the right ventricle to pulmonary artery conduit. The procedure was complicated by valve migration into the right ventricle requiring emergent surgical removal using inflow‐occlusion technique to avoid cardiopulmonary bypass. A hybrid off‐pump perventricular approach was then used in the operating room to successfully implant a 26‐mm Edwards Sapien THV under fluoroscopic guidance. © 2010 Wiley‐Liss, Inc.     

Two‐stage percutaneous closure of mitral periprosthetic valvular leak

Periprosthetic valve leak can develop as a complication of valve replacement surgery and may manifest as symptomatic valvular regurgitation, heart failure, or haemolysis. We report a case of severe mitral periprosthetic valve leak requiring a two‐stage percutaneous closure technique with multiple Amplatzer® III vascular plugs.© 2011 Wiley‐Liss, Inc.     

Successful percutaneous management of left main trunk occlusion during percutaneous aortic valve replacement

Transcatheter aortic valve replacement with balloon‐expandable and self‐expandable stent valves is available in Europe. The balloon‐expandable valve is currently being investigated in a randomized trial in the US. We report an uncommon complication of left main trunk occlusion with balloon‐expandable valve deployment and its successful percutaneous management. Left main trunk occlusion was immediately recognized when patient did not recover blood pressure after valve deployment. TandemHeart? support was used to stabilize the patient immediately and left main trunk was successfully stented. Analysis of anatomy leading to this complication and potential measures to predict and prevent such a complication are discussed in this report. © 2009 Wiley‐Liss, Inc.     

Endocarditis of amplatzer® occluder devices after percutaneous closure of a mitral paravalvular leak

Symptomatic paravalvular leaks (PVL) are a relatively uncommon, but potentially significant postoperative complication of valve replacement surgery. Percutaneous repair of PVLs has become an increasingly utilized approach in patients whose comorbidities obviate surgical repair. We present an interesting case of a gentleman who underwent successful repair of a mitral PVL with Amplatzer devices following initial aortic and mitral valve replacements for bacterial endocarditis. He later developed fungal endocarditis that ultimately required re‐operation to remove the devices and replace his mitral and aortic valves. This complication of closure devices, although reportedly rare, should be considered when contemplating a percutaneous approach. © 2012 Wiley Periodicals, Inc.     

“Valve in valve” implantation of two self‐expandable transcatheter aortic valves in a patient with aortic root aneurysm and massive aortic regurgitation: “A new TAVI option”

Catheter‐based treatment of aortic regurgitation (AR) often proves challenging especially due to associated anatomical difficulties. Here, we present a case of CoreValve implantation with a novel use of the valve‐in‐valve technique to effectively treat severe AR in a patient with repeated cardiac surgery and aneurismatic prosthetic ascending aorta. © 2013 Wiley Periodicals, Inc.     

Sequential trans‐catheter aortic valve implantation and abdominal aortic aneurysm repair

Aortic stenosis in the elderly population is an increasing problem, with many patients being considered too high risk for surgery, and therefore being denied treatment. A percutaneous method of treatment in the form of trans‐catheter aortic valve implantation (TAVI) is becoming an increasingly attractive option in this group of patients. Although, TAVI has been shown to be successful and improve cardiovascular haemodynamics, assessment of other comorbidities in this susceptible group of patients is essential to ensure good clinical outcomes. The presence of an abdominal aortic aneurysm (AAA) in our patient was an example of an important comorbidity which could have a significant impact on the outcome of TAVI, if not managed appropriately. The increased systolic pressure post successful TAVI will result in an increased strain within the AAA with an increased risk of rupture. Therefore, a timely management strategy for the AAA was necessary. Our case is of sequential TAVI followed by Endovascular aneurysm repair (EVAR). The patient underwent uncomplicated TAVI. There was complete abolition of trans‐aortic gradient. EVAR was successfully undertaken three weeks post TAVI. The patient made an excellent recovery and remained well at six months follow‐up. Our case highlights the importance of a detailed assessment in all patients prior to consideration for TAVI and the importance of having a management strategy for both pathologies tailored to the patient. This case demonstrates the benefits of development of trans‐catheter techniques for two different conditions. Future developments including reduction of sheath size reduction and EVAR and TAVI device evolution, may enable simultaneous treatment of aortic stenosis and abdominal aortic aneurysm as a combined percutaneous procedure under local anaesthetic. © 2011 Wiley Periodicals, Inc.     

Percutaneous treatment of a post‐TAVI ventricular septal defect: A successful combined procedure for an unusual complication

In this report, we present the successful percutaneous ventricular septal defect (VSD) closure, just 1 week post‐transcatheter aortic valve implantation (TAVI). Periprocedurally, after implantation of the 31‐mm CoreValve in an intentionally “high” position, we balloon postdilated, with an excellent result. A week post‐TAVI, the patient started to deteriorate. Echocardiogram revealed a good working prosthesis; however, a perimembranous VSD was evident, causing significant shunt. We proceeded with interventional treatment of the defect, using an Amplatzer multifenestrated—“Cribriform”—septal occluder. Six months after the combined procedure, the patient showed marked improvement in symptoms and no shunt was observed. © 2012 Wiley Periodicals, Inc.