How to perform a late explantation of a Sapien XT transcatheter aortic prosthesis

Starting as a therapeutically option for high-risk surgical patients with degenerative aortic valve stenosis, the transcatheter aortic valve implantation method is probably going to become the method of choice for this pathology also in younger and low-risk patients. As bioprosthesis are prone to degeneration, requiring a redo procedure, whenever a valve in valve procedure is contraindicated, a surgical valve replacement will become necessary. We describe a simple surgical method for explantation of a Sapien XT prosthesis that was implanted 7 years previously in a calcified aortic valve.     

When a Mechanical Valve Goes Freestyle: A Patient Tailored Valve-In-Valve Implantation

In case of a redo operation after a full root replacement there are two possible options: replacing the entire root or performing a more conservative valve-in-valve implantation. Regarding the relatively high morbidity and mortality of a redo root replacement, the valve-in-valve implantation is the preferred choice if technically feasible. We present the case of a valve-in-valve implantation with a St. Jude mechanical valve in a Medtronic bioprosthesis in a 57-year old man. Follow-up echocardiography after 1 month showed a mean gradient of 17 mmHg and no paravalvular leakage. The combination of a St. Jude bileaflet mechanical valve implanted in a Freestyle root prosthesis has not been described. This case shows that patient tailored treatment with a St. Jude bileaflet mechanical valve in a Freestyle aortic root valve can be safely performed and might be the preferred choice for younger patients, if technically feasible.     

TAVI for pure aortic valve insufficiency in a patient with a left ventricular assist device

We report transcatheter aortic valve implantation (TAVI) for pure aortic valve insufficiency in a patient with an otherwise normal aortic valve and a long-term left ventricular assist device (LVAD). An oversized 29-mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA) was implanted in the 21-mm native aortic valve annulus. Despite the complete absence of aortic calcifications, the prosthesis remained stably anchored inside the annulus. The reported experience demonstrates that TAVI is feasible even in patients with pure aortic valve regurgitation and can be a reasonable option in patients with aortic regurgitation after LVAD implantation.     

Transcatheter aortic valve-in-valve-in-valve implantation for a failed xenograft

A 78-year-old gentleman with a diagnosis of symptomatic severe xenograft aortic stenosis with multiple comorbidities was referred for transcatheter aortic valve implantation, that is, a "valve-in-valve" procedure. Transcatheter aortic valve implantation was performed by transapical approach using a balloon-expandable bioprosthesis. During valve deployment, the prosthesis moved toward the left ventricle and a second balloon-expandable valve was implanted within the first one-a "valve-in-valve-in-valve" to avoid further ventricular embolization of the first bioprosthesis. Echocardiography at hospital discharge showed a residual mean transvalvular gradient of 17 mm Hg and trivial paravalvular aortic regurgitation. At 1 year follow-up, the patient was in New York Heart Association functional class II.     

Implantation of transcatheter aortic valve prosthesis through the ascending aorta concomitant with coronary artery bypass grafting without cardiopulmonary bypass

Introdution

The transcatheter aortic valve implantation in the treatment of high-risk symptomatic aortic stenosis has increased the number of implants every year. The learning curve for transcatheter aortic valve implantation has improved since the last 12 years, allowing access alternatives.

Objective

The aim of this study is to approach the implantation of transcatheter aortic valve through transaortic via associated with off-pump cardiopulmonary bypass surgery in a 67-year-old man, with chronic obstructive pulmonary disease, arterial hypertension and kidney transplant.

Methods

Off-pump coronary artery bypass surgery was performed and the valve in the aortic position was released successfully.

Results

There were no complications in the intraoperative and postoperative period. Gradient reduction, effective orifice increasing of the prosthesis and absence of valvular regurgitation after implantation were observed by transesophageal echocardiography.

Conclusion

Procedural success demonstrates that implantation of transcatheter aortic valve through the ascending aorta associated with coronary artery bypass surgery without CPB is a new option for these patients.     

Transcatheter valve-in-valve implantation Edwards Sapien XT in a direct flow valve after early degeneration

In recent years, the use of bioprosthetic valve (BPV) has increased significantly with both surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) due to reasons such as the advantage of not using anticoagulants. Nevertheless, major disadvantage of all BPV is the risk of early structural valve deterioration, leading to valve dysfunction, and requires reoperation, which significantly increases the risk of mortality or major morbidity especially after SAVR. There are a limited number of TAV-in-TAV case reports due to TAVI BPV degeneration. In our knowledge, this is the second report of TAV-in-TAV implantation wherein a previously implanted transfemoral 25-mm nonmetallic Direct Flow SVD valve treated with ViV TAVI via Edwards Sapien XT.     

A case of SAPIEN XT valve fallen into left ventricle during valve-in-valve transcatheter aortic valve implantation

Late transcatheter heart valve embolization is a rare but life-threatening complication of transcatheter aortic valve implantation. Surgical intervention is performed for most cases, but some cases were treated by valve-in-valve transcatheter aortic valve implantation. We describe a patient in whom a 29-mm Edwards SAPIEN XT valve migrated into the left ventricular outflow tract 41 days after the initial implantation. We tried to perform valve-in-valve transcatheter aortic valve implantation using a transfemoral approach. As soon as the second transcatheter heart valve touched the first implanted valve, it fell into the left ventricle. Immediate surgical intervention was required. The first valve was removed, and surgical aortic valve replacement was successfully performed. In conclusion, we should choose surgical aortic valve replacement for late transcatheter heart valve embolization. Even if we need to treat by catheter intervention, transapical approach may be better.     

First Transcatheter Aortic Valve Implantation via Carotid Artery Performed in Japan

Transcatheter aortic valve implantation (TAVI) through a peripheral arterial access is often complicated by concomitant arteriopathy. We describe here the first successful case of TAVI through the carotid artery in Japan. The patient was an 83-year-old woman with severe aortic stenosis (AS). Preoperative computed tomography (CT) revealed a shaggy distal aortic arch and left subclavian artery ostium, along with severely calcified bilateral iliofemoral arteries. Trans-apical and direct aortic approaches were abandoned because of frailty. Following the thorough cerebrovascular assessment, the left common carotid artery was selected for arterial access and a CoreValve transcatheter aortic valve was successfully implanted without neurologic complications.     

Severe aortic insufficiency after transapical aortic valve implantation

We report the dislocation of a stented aortic valve prosthesis two weeks after the uneventful transapical implantation in a female who had underwent mitral valve replacement and CABG six years before. The initial implantation of the Edwards Sapien aortic valve prosthesis (Edwards Lifesciences, Irvine, CA), as well as the postoperative recovery, was uneventfully. At the sixth postoperative day, the patient developed a progressive heart failure due to a severe aortic insufficiency. During conventional aortic valve replacement, the dislocated prosthesis was found in the left ventricle. After uncomplicated postoperative recovery, the patient could be discharged in a good physical condition. Preexisting mitral valve prosthesis seems to be an important, complicating goal for transcatheter aortic valve implantation.     

A cost-utility analysis of transcatheter versus surgical aortic valve replacement for the treatment of aortic stenosis in the population with intermediate surgical risk

Objective

Although transcatheter aortic valve implantation has been shown to be noninferior to surgical aortic valve replacement in patients with severe aortic stenosis at intermediate surgical risk, the cost-effectiveness of this strategy in this population is unknown. Our objective was to conduct a cost-utility analysis comparing transcatheter aortic valve implantation with surgical aortic valve replacement in the population with intermediate risk severe aortic stenosis.

Postcardiac transplant transcatheter core valve implantation for aortic insufficiency secondary to Impella device placement

Conventional cardiac surgical procedures or transcatheter interventions after orthotopic heart transplantation are generally uncommon. We report the case of a 45-year-old woman who developed severe aortic insufficiency after insertion of a 5-L Impella device 16 weeks after heart transplantation. After joint evaluation by the transcatheter valve team, transcatheter aortic valve implantation was planned because of associated comorbid conditions. A 29-mm CoreValve prosthesis (Medtronic, Minneapolis, MN) was inserted percutaneously. At 6 months after prosthesis implantation, the patient was asymptomatic in New York Heart Association functional class II, and the echocardiogram showed a mean transvalvular gradient of 1 mm Hg, an aortic valve area of 1.5 cm2, and no paravalvular aortic insufficiency.     

Perforation of the Valsalva sinus after implantation of Medtronic Freestyle aortic bioprosthesis

We report on structural valve deterioration in patients with the Medtronic Freestyle aortic bioprosthesis (Medtronic, Inc, Minneapolis, MN), including spontaneous perforation of the Valsalva sinus. These occurred in four prosthesis in 3 patients using the modified subcoronary method or full root technique. One patient died of ruptured pseudoaneurysm and the others survived reoperation well. Careful follow-up is required after Freestyle bioprosthesis implantation.     

Use of an inverted On-X mitral valve in the aortic position in a resource limited setting

Implanting an inverted aortic valve prosthesis in the mitral position has shown to be a viable solution for a small mitral annulus. We describe a case of implanting an inverted in the mitral prosthesis in the aortic position in a patient with an excessively large aortic annulus. A 46-year-old male with severe aortic insufficiency underwent aortic valve replacement during a surgical outreach program in Tegucigalpa, Honduras. Aortic valve annulus measured 30 mm on preoperative echocardiogram. An inverted On-X mechanical mitral heart valve with Conform-X sewing ring 25/33 mm was implanted with an excellent hemodynamic result and no paravalvular leak. To the best of our knowledge, this case demonstrates the first inverted mitral prosthesis implanted in the aortic valve position.     

Konventioneller Aortenklappenersatz

Aortic valve surgery in Germany has changed in the last 10 years. Looking at the data of the German Society of Thoracic and Cardiovascular Surgery, in 2006 transcatheter aortic valve implantation (TAVI) was performed in 0.7?% of patients, whereas in 2014 TAVI was performed in 46.3 % of patients with indications for aortic valve replacement (AVR); however, the number of conventional AVRs rose from 11,011 to 11,764 between the years 2005 and 2014. During the same period a significant shift was seen regarding the selection of a mechanical versus a biological aortic valve prosthesis and the number of implanted mechanical aortic valves compared to biological aortic valve prostheses went down from 45.6?% to 13.1?%. In parallel, the number of patients between 20 and 70 years old went down from 54.8?% to currently only 45.7?%. What are the criteria for the choice of a mechanical or biological aortic valve prosthesis? The intention of this article is to be supportive in finding the “optimal” aortic valve prosthesis for individual patients.     

Trans-catheter aortic valve implantation after previous aortic homograft surgery

In patients with previous heart surgery, the operative risk is elevated during conventional aortic valve re-operations. Trans-catheter aortic valve implantation is a new method for the treatment of high-risk patients. Nevertheless, this new procedure carries potential risks in patients with previous homograft implantation in aortic position. Between April 2008 and February 2011, 345 consecutive patients (mean EuroSCORE (European System for Cardiac Operative Risk Evaluation): 38 ± 20%; mean Society of Thoracic Surgeons (STS) Mortality Score: 19 ± 16%; mean age: 80 ± 8 years; 111 men and 234 women) underwent trans-apical aortic valve implantation. In three patients, previous aortic homograft implantation had been performed. Homograft degeneration causing combined valve stenosis and incompetence made re-operation necessary. In all three patients, the aortic valve could be implanted using the trans-apical approach, and the procedure was successful. In two patients, there was slight paravalvular leakage of the aortic prosthesis and the other patient had slight central leakage. Neither ostium obstruction nor mitral valve damage was observed. Trans-catheter valve implantation can be performed successfully after previous homograft implantation. Particular care should be taken to achieve optimal valve positioning, not to obstruct the ostium of the coronary vessels due to the changed anatomic situation and not to cause annulus rupture.     

Transapical implantation of a self-expanding aortic valve bioprosthesis — animal feasibility study

Background: Severe peripheral arterial disease may pose a limitation to the applicability of trans-arterial aortic valve implantation in patients who are otherwise candidates. For this reason, transapical aortic valve implantation has been proposed as a possible alternative. Objective: To evaluate the acute safety and performance of a specially designed delivery system, the CoreValve Tranzap™ delivery catheter, for the transapical implantation of a self-expandable aortic valve prosthesis in a porcine animal model. Methods: Thirteen pigs were implanted with a self-expandable aortic valve bioprosthesis using a 21F catheter delivery system through a transapical approach. The delivery system was evaluated for: (1) the ability to access the implantation site; (2) the ability to precisely position the delivery catheter; (3) control of the delivery of the prosthesis; (4) safe retrieval of the delivery catheter; and (5) the ability to close the apical access site of the heart. Results: Successful implantation was achieved in 100% of the cases. The following points were achieved in all animals: (1) passage of the delivery catheter through an incision in the left ventricular apex; (2) positioning of the delivery catheter on the implantation site; (3) controlled deployment of the aortic valve prosthesis; (4) the safe retrieval of the delivery catheter system; and (5) the adequate closure of the apex of the heart. Conclusion: This study demonstrates the acute safety and feasibility of the CoreValve Tranzap™ delivery system for the transapical implantation of the CoreValve self-expanding aortic valve bioprosthesis in a porcine animal model.     

Direct transaortic transcather valve-in-valve implantation into a mechanical aortic valve prosthesis during left ventricular assist device implantation: description of a surgical technique

The presence of a mechanical aortic valve prosthesis is considered a relative contraindication for left ventricular assist device implantation (LVAD) due to the occurrence of thromboembolic events. Five patients were operated on for LVAD implantation with status post mechanical aortic valve implantation (n = 3 with status post Bentall procedure). After removal of the leaflets, a transcatheter balloon-expandable valve was placed within the mechanical ring in all patients. Three patients were discharged from hospital with a maximum follow-up of 3.3 years. Transaortic transcatheter valve implantation into a mechanical aortic valve during LVAD implantation is a feasible option. It reduces operative times and might also prevent thromboembolic events.     

Aortic valve replacement with a stentless porcine aortic root bioprosthesis

From April, 1999 to November, 1999, 8 patients underwent the aortic valve replacement using Medtronic Freestyle aortic root bioprosthesis. Mean age was 67.8 years old. Aortic valve etiology was as follows, AS: 1 case, AR: 2 cases, ASR: 3 cases, IE: 1 case, mechanical valve malfunction due to subvalvular pannus: 1 case. The implanted valve size was 25: 2 cases, 23: 3 cases, 21: 1 cases, 19: 2 cases. Surgical technique was subcoronary: 7 cases, full-root: 1 case. Post-op 2D-echo revealed tribial aortic valve incompetence in two cases because of size discrepancy between the aortic annulus and the ascending aorta. Pacemaker implantation was needed in 1 case because of the complete A-V block. In comparison with 5 cases of aortic valve replacement with Hancock II performed in same period, there were no significant differences about the implanted valve size and mean systolic pressure gradient, but the effective orifice area in Freestyle cases was significantly larger than Hancock II cases.     

Single‐session double valve replacement: TAVI+tricuspid valve‐in‐valve procedures

We describe a 70‐year‐old lady with rheumatic heart disease and a history of the mitral valve and tricuspid valve replacement, who underwent transcatheter aortic valve implantation and the tricuspid valve‐in‐valve procedure in a single session.     

The influence of native aortic valve calcium and transcatheter valve oversize on the need for pacemaker implantation after transcatheter aortic valve insertion

Objective

Native aortic valve calcium and transcatheter aortic valve oversize have been reported to predict pacemaker implantation after transcatheter aortic valve insertion. We reviewed our experience to better understand the association.