Transcatheter aortic valve implantation 10 years after valve‐in‐valve transcatheter aortic valve implantation for failing aortic valve homograft root replacement

Valve‐in‐valve transcatheter aortic valve implantation (ViV‐TAVI) is an established therapy for a degenerated surgical bioprosthesis. TAVI‐in‐TAVI following ViV‐TAVI has not been previously performed. We report a high‐risk patient presenting with severe left ventricular failure secondary to undiagnosed critical aortic stenosis due to degeneration of the implanted transcatheter heart valve more than a decade after initial ViV‐TAVI for a failing stentless aortic valve homograft. Successful TAVI‐in‐TAVI reversed the clinical and echocardiographic changes of decompensated heart failure with no evidence of coronary obstruction.     

Alternative access routes for transcatheter aortic valve implantation (TAVI)

The transcatheter aortic valve implantation (TAVI) is a preferred treatment option among the patients with severe aortic stenosis who were considered to be non-operable or at high surgical risk. The basic principle of the crimped valve and the catheter-based implantation to the stenotic native valve remains unchanged, but several different concepts of bioprosthesis and approaches of valve implantation have been developed. All the concepts have proven their safety and efficiency, however, there are only limited data available comparing one approach to another. The objective of this paper is to offer an overview and more detailed specification of current TAVI access techniques.     

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.     

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.     

Late subannular aortic root rupture following transcatheter aortic valve implantation presenting as ST elevation myocardial infarction

Transcatheter aortic valve implantation (TAVI) has transformed the treatment of severe aortic stenosis. Here, we present a case of late aortic root rupture presenting as ST‐elevation myocardial infarction five weeks following successful TAVI. Aortic root rupture is a rare complication of TAVI, which occurs in ～1% of procedures and usually arises during or soon after the procedure and is associated with high mortality (～50%). Early recognition of late‐presenting complications related to TAVI, including aortic root rupture, is essential for specialists and nonspecialists. © 2016 Wiley Periodicals, Inc.     

Performance of valve-in-valve for severe para-prosthetic leaks due to inadequate transcatheter aortic valve implantation

Objectives : This study reports on mid‐term safety and performance of valve‐in‐valve implantation as rescue strategy to overcome acute PPL after TAVI. Background. Moderate to severe para‐prosthetic leaks (PPL) after transcatheter aortic valve implantation (TAVI) have been described with both self‐expandable and balloon‐expandable device.Methods : We analyzed data regarding patients who underwent valve‐in‐valve implantation, enrolled in the ongoing single‐center prospective registry of TAVI, the Padova University REVALVing experience Registry. All procedures were performed by a totally percutaneous approach, using the self‐expanding Medtronic CoreValve (Medtronic, Minneapolis, MN). Results : Out of 87 patients who underwent TAVI, six received valve‐in‐valve implantation because of persisting severe PPL, due to prosthesis malposition. In all patients, the second device was successfully deployed, with a significant reduction in aortic regurgitation: PPL was no longer appreciable in two of six patients, and it decreased from severe to mild or trivial in four patients. Four patients developed atrio‐ventricular block requiring pace‐maker implantation. At follow‐up (6–24 months) two patients died, whereas no prosthesis‐related death occurred. Transprosthesis pressure gradient, effective orifice area, and aortic regurgitation did not change at serial echocardiograms throughout the follow‐up. Conclusions : Valve‐in‐valve implantation using self‐expandable bioprosthesis seems safe and highly effective to overcome severe PPL due to prosthesis malposition early after TAVI. Moreover, the implantation of two valves does not affect the performance of prosthesis at follow‐up. © 2011 Wiley Periodicals, Inc.     

Successful percutaneous implantation of symetis ACURATE neo transcatheter aortic bioprosthesis for the treatment of pure aortic regurgitation

Transcatheter aortic valve implantation (TAVI) was initially developed for the treatment of calcific aortic stenosis. In the recent years, however, TAVI has been used to treat selected patients with pure, severe AR. We report successful transfemoral implantation of a Symetis ACURATE neo bioprosthesis in a severely symptomatic, 87‐year‐old woman with pure AR and major comorbidities. We decided to use the ACURATE neo bioprosthesis for some of its features appeared to us as potentially useful in the setting of pure AR: the stabilization arches ensure perfect coaxial alignment and extreme stability of the device during deployment, and the “waist” and the skirt were considered useful to obtain a good seal in the absence of significant valvular and annular calcifications. Finally, we decided to use a self‐expanding valve to minimize the trauma to the aortic annulus. The procedure was successful and the patient was discharged home on postoperative day 3. At the 3‐month control echocardiography, there was no residual AR, and the mean transprosthetic gradient was 3 mm Hg. The current case demonstrates that percutaneous TAVI with the ACURATE neo bioprosthesis may be used to treat pure, isolated AR in selected patients. The device has several interesting features that could make it advantageous in this setting. © 2016 Wiley Periodicals, Inc.     

Delivery balloon‐induced ascending aortic dissection: An unusual complication during transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a relatively mature technique that is generally accepted as a promising treatment for inoperable patients and those who are high‐risk candidates for surgical aortic replacement. Although severe complications in the aortic valve complex, such as annular or aortic root rupture, are not frequently observed, these events could easily lead to catastrophic outcomes, and therefore remain major issues during TAVI. However, there remains a paucity of data describing these catastrophic complications because of their low incidence. We encountered the case of an 88‐year‐old woman complicated by a dissection of the ascending aorta during TAVI from an “unusual” cause: injury due to the delivery of a balloon‐expandable valve to a very narrow and heavily calcified sinotubular junction (STJ). This is the first report to demonstrate the mechanism of this complication; even a delivery balloon, not a stent frame, with low inflation pressure might injure a narrow STJ and lead to an aortic dissection. Therefore, the use of oversized delivery balloons should be avoided in patients with a narrow and calcified STJ. © 2015 Wiley Periodicals, Inc.     

Distortion of the CoreValve during transcatheter aortic valve-in-valve implantation due to valve dislocation

Nowadays transcatheter aortic valve implantation (TAVI) is an accepted alternative to surgical aortic valve replacement for high-risk patients (pts). Successful TAVI procedures for failed aortic surgical bioprosthesis (TAV-in-SAV) have already been reported. In the presented two cases of TAV-in-SAV implantation a strut distortion of the stent was revealed on angiographic imaging and confirmed on control CT scan. In both procedures, a dislocation of the medtronic core valve (MCV) prosthesis during implantation led to valve retrieval, with a necessity of reloading it in the 18F introducer before subsequent implantation of the same valve in correct position.     

“TAVI: Valve in valve. A new field for structuralists? Literature review”

Transcatheter aortic valve implantation (TAVI) led to the foundation of the subspecialty of structural heart interventions and created an emerging area of clinical and technical issues. Soon after TAVI introduction into clinical practice, boundaries were expanded with utilization of valve-in-valve (V-i-V) techniques. V-i-V comprised a diverse subset of patients including TAVI within TAVI, TAVI within a degenerated surgically implanted bioprosthesis, or even TAVI-in-TAVI-in-surgical bioprosthesis. In the present review, we summarize the available literature and present initial experience on the field in Greece.     

超声心动图在主动脉瓣狭窄经导管主动脉瓣植入术中的应用价值

目的探讨超声心动图在主动脉瓣狭窄患者经导管主动脉瓣植入术中的作用。方法3例重度主动脉瓣瓣膜狭窄患者接受经导管主动脉瓣人工瓣膜植入术。使用PhilipS iE33型彩色多普勒超声诊断仪,配备经胸探头S5—1和经食道探头S7—2,X7—2t。超声观察内容包括明确主动脉瓣膜病变范围和程度,测量主动脉瓣环前后径,人工瓣膜植入术后瓣膜功能等。结果3例患者经导管主动脉瓣植入术均取得了成功,人工瓣膜位置稳定,常规超声心动图3例患者术前经胸超声心动图与术中经食管超声心动图诊断相符,跨瓣压差较术前明显下降,主动脉瓣瓣上流速明显下降,瓣周漏瞬时反流量平均约1．2mL。结论经导管主动脉瓣人工瓣膜植入术在治疗严重主动脉瓣瓣膜狭窄中方法可行,效果良好;超声心动图在这项工作中具有重要的辅助作用。     

Transcatheter aortic valve implantation using direct aortic access: first procedures in Poland

Transcatheter aortic valve implantation (TAVI) is an alternative option for the treatment of severe aortic stenosis in patients carrying an elevated operative risk of conventional surgical aortic valve replacement (AVR). Recently, data from randomised clinical trials confirmed superiority of TAVI when compared with the conservative treatment in inoperable patients, and its non-inferiority when compared with AVR in a high-risk population. Transfemoral vascular access remains the preferred route for delivering the bioprosthesis. However, in a significant proportion of patients, the presence of severe iliac-femoral arteriopathy or small vessel diameter render the transfemoral approach unusable. In this article, we report the first Polish experience of two successful TAVI procedures with bioprostheses (both balloon- and self-expandable) delivered using direct aortic access.     

Preferential short cut or alternative route: the transaxillary access for transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has gained widespread acceptance as a treatment option for patients at high risk for conventional aortic valve replacement. The most commonly used access site for TAVI is the common femoral artery. Yet, in a significant number of patients the transfemoral access is not suitable due to peripheral vascular disease of the lower extremity. In these cases the transaxillary approach can serve as an alternative implantation route. By considering the anatomical requirements and providing an adequate endovascular “safety-net” during the procedure the transaxillary TAVI approach results in excellent procedural and clinical outcome. However, whether the transaxillary access for TAVI is superior to other non-transfemoral approaches (e.g., transapical or direct aortic) needs to be studied in the future in a prospective randomized trial.     

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.     

Successful treatment of aortic root rupture following transcatheter aortic valve implantation in a heavily calcified aorta: A novel approach to a serious complication

Aortic root rupture during transcatheter aortic valve implantation (TAVI) is an uncommon but almost uniformly fatal complication. We describe a novel surgical management of this complication using a combination of pledgeted sutures and prolonged direct digital compression with biomatrix and lattice adjuncts. Furthermore, our patient underwent percutaneous coronary intervention with endothelial progenitor cell‐capturing stents, which facilitated TAVI to be performed off clopidogrel therapy. We believe the use of these stents reduced the severity of hemorrhage following aortic root rupture and helped maintain vessel patency following prolonged hypotension. © 2012 Wiley Periodicals, Inc.     

Transfemoral aortic valve implantation in pure native aortic valve insufficiency using the repositionable and retrievable lotus valve

Transfemoral aortic valve implantation (TAVI) for the treatment of pure native aortic insufficiency is not routine clinical practice. Absent cusp calcification, missing landmarks in combination with no perfect valve control during release with first‐generation TAVI devices resulted in a high rate for need of a second valve or relevant residual aortic insufficiency. We report the first case with a native pure aortic valve insufficiency at high surgical risk successfully treated by implantation of the repositionable and completely retrievable Lotus valve, resulting in a well‐controlled and safe procedure with no residual aortic insufficiency. © 2015 Wiley Periodicals, Inc.     

经导管主动脉瓣置换术的新进展

近年来,经导管主动脉瓣置换(TAVI)术发展迅猛。对于外科手术风险很高的严重主动脉瓣狭窄患者,TAVI术已成为一种替代治疗。随着器械的不断改进和临床经验的积累,一些新的技术开始应用于TAVI领域,如非传统的支架输送途径、新材料的带瓣膜支架、局部麻醉下的TAVI术、经导管"瓣中瓣"技术等等。本文将TAVI领域近年来出现的一些新技术作一介绍。     

Transcatheter aortic valve implantation through a diseased left common carotid artery: Combined approach with endarterectomy and left carotid‐subclavian bypass

We report a case of transcatheter aortic valve implantation (TAVI) with the self‐expanding Medtronic CoreValve bioprosthesis (Medtronic, Minneapolis, MI) through a diseased left common carotid (LCC) artery. This 81‐year‐old male patient presented with heart failure due to a severe degenerative aortic valve stenosis. Comorbidities included diabetes, hypertension, and dyslipidemia as well as peripheral and coronary artery disease, resulting in a logistic EuroScore II of 25.9%. Consequently, he was rejected to undergo surgery and a transcatheter approach was planned. Due to severe peripheral vascular disease with iliofemoral lesions, significant calcifications and unfavourable angulations of the innominate artery as well as prior bypass surgery precluding a direct aortic and subclavian approach, none of the established access sites were suitable. Therefore, we considered a left carotid access, which had to be combined with a surgical endarterectomy for treatment of a significant common carotid bifurcation stenosis and left subclavian‐LCC permanent tunnel bypass graft. The procedure was successful without cardiac, cerebrovascular, or access complications. This case illustrates a true heart team approach, establishing a unique access for TAVI for patients without regular access options. © 2012 Wiley Periodicals, Inc.     

Transaortic transcatheter aortic valve implantation using edwards sapien valve

Objectives: To evaluate feasibility and outcome of Transoartic Transcatheter Sapien valve implantation. Background: Transcatheter Aortic valve implantation (TAVI) using the Edwards SAPIEN device (Edwards LifeScience, Irvine, CA) is usually performed via the transfemoral (TF) or transapical (TA) routes. Some patients are not suitable for these approaches. We report our experience with the novel transaortic (TAo) approach via a partial upper sternotomy and discuss the advantages and future applications. Methods: Between January 2008 to March 2011 193 patients with severe aortic stenosis underwent TAVI with the Edwards SAPIEN bioprosthesis at the St. Thomas' Hospital, London. 108 patients were unable to undergo a TF‐TAVI and of those 17 were accepted for a TAo‐TAVI on the basis of anatomy, risk, LV function, and significant respiratory disease. Results: The TAo‐TAVI group (n = 17) had more prevalent respiratory disease than the TA‐TAVI group (47.0% vs. 18.7%, P = 0.011). Otherwise the groups were similar in demographics and history. Despite this the 30 day mortalities were not significantly different between the groups (TAo‐TAVI 4.3% at 30 days versus TA‐TAVI 7.7%, P = 0.670). There were no significant differences in procedural complications. Conclusions: The TA‐TAVI approach may not be desirable in patients with severe chest deformity, poor lung function or poor left ventricular function. TAo‐TAVI via a partial sternotomy is safe and feasible in these patients. © 2011 Wiley Periodicals, Inc.     

Transcatheter Valve-in-Valve implantation after late migration of balloon expandable Sapien- XT prosthesis in a severe pure aortic regurgitation case

Transcatheter aortic valve implantation (TAVI) is an off label therapy in patients with severe, symptomatic, native aortic regurgitation (NAR) and porcelain aorta. Prosthetic valve migration (PVM) after TAVI occur with an incidence of 1.3% per patient-year. The Valve-in-Valve (TV-in-TV) implantation in an overlapping fashion is used as a rescue therapy to avoid cardiac surgery due to valve-malapposition. We report a PVM occurring late, i.e., 7 days after TAVI treated with a second valve implantation via transfemoral approach.