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.     

Edwards Sapien 3 transcatheter aortic valve implantation for management of severe aortic regurgitation in a teenage patient with corrected atrioventricular septal defect and progressive left ventricular dysfunction

Transcatheter aortic valve replacement is mostly performed in elderly patients with severely calcified aortic valves. There are few reports about its use for pure aortic regurgitation, few reports about its use in adolescent patients and to the best of our knowledge no report about the use of an Edwards Sapien valve in the aortic position in an underage patient after surgically corrected congenital heart disease (CHD). Decompensation of a complex CHD can be difficult to manage and may require unusual solutions. We report a case of a teenage patient presenting with progressive aortic regurgitation and deterioration of left ventricular function after multiple surgical procedures for an atrioventricular septal defect (AVSD). As “bridge‐to‐transplant,” we performed a transcatheter aortic valve implantation using a balloon‐expandable Sapien 3 prosthesis. At 6 month follow‐up, the patient remained clinically stable with no rehospitalization due to heart failure.     

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.     

Aortic aneurysm 18 month after transfemoral implantation of a self‐expandable aortic valve prosthesis

We report a case of a new developed aortic aneurysm 18 month after transcatheter aortic valve implantation in an 80‐year‐old woman. The abnormality was an incidental finding during routine coronary angiography. © 2013 Wiley Periodicals, Inc.     

Balloon valvuloplasty treatment of an infolded CoreValve

Transcatheter aortic valve replacement is an approved treatment for select patients with severe aortic stenosis. A rare complication of self‐expanding transcatheter heart valves (THVs) is infolding of the valve stent frame, which results in a malopposed segment, perivalvular aortic insufficiency, and possibly leaflet dysfunction. We report here a successful case of balloon valvuloplasty treatment for severe infolding of a self‐expandable THV in the aortic position, restoring stent frame geometry and leaflet function. © 2015 Wiley Periodicals, Inc.     

Interventional fellowship in structural and congenital heart disease for adults

Training for structural and adult congenital heart disease interventions remains undeveloped. With the advent of recent percutaneous interventions for the treatment of structural and valvular heart disease, such as transcatheter aortic and pulmonary valve implantation, mitral valve repair, and the expansion of shunt closure procedures, there is a clear need to define the training requirements for this category of procedures. The training needs to be aligned with the goals and priorities of a basic or advanced level and be categorized into acquired and congenital. This document will define the training needs and knowledge base for the developing field of structural heart disease intervention. © 2010 Wiley‐Liss, Inc.     

Angina, aortic stenosis and coronary heart disease.

The pre-operative clinical and haemodynamic findings of 139 consecutive patients with aortic stenosis were analysed in an attempt to determine the incidence and influence of coronary heart disease on the mode of presentation of patients with aortic stenosis. The overall incidence of coronary heart disease was 32%. 105 patients (76%) presented with angina and of these, 41 patients (39%) had significant coronary heart disease as compared to 4 (13%) of the remaining 34 patients who did not present with angina. Clinical parameters including age, sex, severity of angina together with the presence of associated symptoms and precipitating factors were unhelpful in distinguishing those patients with coronary heart disease. Evidence of previous transmural myocardial infarction or the presence of ST-T abnormalities in the absence of digitalis and the changes of left ventricular hypertrophy were reliable electrocardiographic signs of coronary heart disease. Although peak systolic aortic valve gradient tended to decrease with increasing severity of coronary heart disease, the severity of aortic stenosis was not a reliable indicator of the presence of coronary disease. Patients with coronary heart disease in the absence of angina all had a combination of moderate aortic stenosis and single vessel disease. It is concluded that coronary heart disease cannot be predicted in patients with angina and, in the absence of angina occurs with an incidence sufficiently high to advocate the use of coronary angiography as part of the investigation of all patients with aortic stenosis being considered for valve replacement.     

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.     

Mixed aortic valve disease treated with transcatheter aortic valve replacement in a high risk patient presenting with acute decompensated heart failure

Mixed aortic valve disease refers to the combination of aortic regurgitation (AR) and aortic stenosis (AS). Commonly etiologies include a bicuspid aortic valve, rheumatic heart disease, and endocarditis superimposed upon a stenotic aortic valve. Treatment depends upon the severity of disease, the presence of symptoms and the size and function of the left ventricle. We present a case of a young patient that presented with new onset acute decompensated heart failure with mixed aortic valve disease that was successful treated with transcatheter aortic valve replacement (TAVR). Invasive hemodynamics at baseline and following TAVR provide an insight into the characteristic features of mixed aortic valve disease. TAVR represents a new treatment option for critically ill patients deemed high risk or nonoperable for surgical aortic valve replacement.     

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

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

主动脉瓣疾病冠脉造影分析

目的　观察主动脉瓣疾病患者合并冠状动脉病变的发生情况。方法　对 10 5例主动脉瓣疾病不合并二尖瓣病变的患者术前临床资料和选择性冠状动脉造影的结果进行综合分析。结果　 10 5例患者中 5 1例有心绞痛症状 ,心绞痛发生率为 48 6% ,但冠脉造影显示只有 7例诊断冠心病。主动脉瓣狭窄病变为主者心绞痛的发生率为 68 2 % ,以主动脉瓣关闭不全病变为主者 ,心绞痛的发生率为 3 2 0 % ,两者比较有统计学差异 (P <0 0 1)。但是 ,两者冠心病的发病率无统计学差异。主动脉瓣退行性变组合并冠心病率(3 3 3 % )显著高于风心病组和先天性二叶瓣组 (P <0 0 1)。结论　在单纯主动脉瓣病变中以心绞痛预测冠心病的敏感性、特异性、准确率低。而主动脉瓣退行性变合并冠心病的发病率大于风心病和先天性的主动脉瓣病变。在单纯主动脉瓣病变者明确有无合并冠心病 ,冠脉造影是必要的 ,尤其是主动脉瓣退行性变病人     

Incidence of coronary artery disease in patients with valvular heart disease.

The case notes, cardiac catheterisation data, and coronary arteriograms of 239 patients investigated for valvular heart disease during a five year period were reviewed. Angina present in 13 of 95 patients with isolated mitral valve disease, 43 of 90 patients with isolated aortic valve disease, and 18 of 54 patients with combined mitral and aortic valve disease. Significant coronary artery disease was present in 85 per cent of patients with mitral valve disease and angina, but in only 33 per cent of patients with aortic valve disease and angina. Patients with no chest pain still had a high incidence of coronary artery disease, significant coronary obstruction being present in 22 per cent with mitral valve disease, 22 per cent with aortic valve disease, and 11 per cent with combine mitral and aortic valve disease. Several possible clinical markers of coronary artery disease were examined but none was found to be of practical help. There was, however, a significant inverse relation between severity of coronary artery disease and severity of valve disease in patients with aortic valve disease. Asymptomatic coronary artery disease is not uncommon in patients with valvular heart disease and if it is policy to perform coronary artery bypass grafting in such patients, routine coronary arteriography must be part of the preoperative investigation.     

Valve‐in‐valve‐in‐valve: Treating endocarditis of a transcatheter heart valve

Transcatheter heart valve endocarditis is a rare, but life threatening complication. We describe the case of a patient who was successfully treated by transcatheter aortic valve‐in‐valve‐in‐valve replacement with a favorable 1‐year outcome, despite severe early complications. © 2015 Wiley Periodicals, Inc.     

Pre‐emptive positioning of a coronary stent in the left anterior descending artery for left main protection: A prerequisite for transcatheter aortic valve‐in‐valve implantation for failing stentless bioprostheses?

Transcatheter aortic valve‐in‐valve (VIV) implantation in high‐risk patients with degenerative surgical bioprosthetic aortic valves is a novel application of transcatheter aortic valve replacement technology. Although transcatheter aortic VIV procedure is clinically effective in most patients, it is a more demanding procedure in terms of the technical aspects of procedural planning. VIV carries a higher risk of coronary occlusion which is associated with a higher rate of in‐hospital mortality. We hereby report a technique of pre‐emptive left main (LM) protection, by positioning a coronary stent in the proximal left anterior descending artery prior to VIV implantation. The patient treated was considered to be at an increased risk of LM occlusion as a result of the procedure. The technique was performed in anticipation of emergent bailout stenting of the LM. As predicted, the LM occluded during the procedure and LM protection facilitated the safe and effective treatment of an otherwise life‐threatening procedure. © 2013 Wiley Periodicals, Inc.     

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

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

Endovascular repair of severe aortic coarctation,transcatheter aortic valve replacement for severe aortic stenosis,and percutaneous coronary intervention in an elderly patient with long term follow-up

To the best of our knowledge, there have not been any reports of total transcatheter approach including stenting of severe coarctation of the aorta (CoA), transcatheter aortic valve replacement (TAVR) for concomitant severe aortic valve stenosis, and percutaneous coronary intervention (PCI) to treat significant coronary artery disease in a single patient. We report a 70-year-old female, who presented with uncontrolled hypertension and acute decompensated heart failure (ADHF) and was found to have severe CoA, severe bicuspid aortic valve (BAV) stenosis, and significant proximal left anterior descending (LAD) coronary artery disease. In a multidisciplinary heart team meeting, we decided to perform an endovascular repair of both cardiac and vascular pathologies using a two-stage approach due to the significant comorbidities; mainly uncontrolled hypertension, type 2 diabetes mellitus, chronic obstructive pulmonary disease, and severe calcifications of the ascending aorta. The procedures were successfully performed and the patient was asymptomatic 30?months later at follow-up and was without any significant gradients across the coarctation or the aortic valve.     

Coronary artery disease and TAVI: Current evidence on a recurrent issue

Coronary artery disease (CAD) is a frequent finding in patients with aortic stenosis (AS). Concomitant coronary artery bypass and aortic valve replacement is considered the gold standard treatment in surgical candidates. However, limited evidence is available regarding the role of coronary revascularization in patients undergoing transcatheter aortic valve implantation (TAVI). How to evaluate CAD severity in patients with AS, whether percutaneous coronary intervention (PCI) needs to be performed and what is the timing for revascularization to minimize procedural risks, remains matters of debate. The aim of this review is to summarize epidemiology, diagnostic tools and possible options for CAD management in patients undergoing TAVI with specific focus on the pros and the cons of the different timing of PCI.     

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.     

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.     

Transcatheter aortic valve‐in‐valve implantation of a corevalve in a degenerated stenotic sapien heart valve prosthesis

Treatment options for re‐stenotic aortic valve prosthesis implanted by transcatheter technique have not been evaluated systematically. We describe the case of a 75‐year‐old dialysis patient who was treated by transcatheter aortic valve implantation 3.5 years ago and now presented with severe stenosis of the percutaneous heart valve. The patient was initially treated with a trans‐apical implantation of an Edwards Sapien 26 mm balloon expandable valve. The patient remained asymptomatic for 3 years when he presented with increasing shortness of breath and significant calcification of the valve prosthesis on transesophageal echocardiography. Valve‐in‐valve percutaneous heart valve implantation using a 26‐mm CoreValve prosthesis was performed under local anesthesia. The prosthesis was implanted without prior valvuloplasty. Pacing with a frequency of 140/min was applied during placement of the valve prosthesis. Positioning was done with great care using only fluoroscopic guidance with the aim to have the ventricular strut end of the CoreValve prosthesis 5 mm higher than the ventricular strut end of the Edwards Sapien prosthesis. After placement of the CoreValve prosthesis within the Edwards Sapien valve additional valvuloplasty with rapid pacing was performed in order to further expand the CoreValve prosthesis. The final result was associated with a remaining mean gradient of 5 mm Hg and no aortic regurgitation. In conclusion, implantation of a CoreValve prosthesis for treatment of a restenotic Edwards Sapien prosthesis is feasible and is associated with a good functional result. © 2012 Wiley Periodicals, Inc.