Balloon aortic valvuloplasty in contemporary practice

Background

There has been a revival of balloon aortic valvuloplasty (BAV) for severe aortic stenosis, as a result of an increasing number of patients undergoing trans‐catheter aortic valve implantation (TAVI). However, there has not been universal adoption of BAV as a standalone, nor bridging therapy.

Methods

A retrospective analysis of the practice at our institution between June 2009 and May 2016 was performed. Demographic, clinical, procedural, and follow‐up data on all patients were collected.

Results

A total of 200 patients with a median age of 82 years and severe symptomatic aortic stenosis underwent BAV from June 2009 to May 2016. All patients had appreciable comorbidity with a mean logistic Euro SCORE of 48 ± 11 and mean standard Euro SCORE 15 ± 4. BAV was performed for palliation in 118 (59%), as a bridging therapy for TAVI in 55 (27.5%) and bridging to surgical AVR in 27 patients (13.5%), respectively. Major complications occurred in 14 patients (7%) including 2 in‐patient deaths (1%). A statistically significant improvement in symptoms and a decrease in trans‐valvular gradient were observed.

Conclusion

BAV is an effective treatment strategy, either as a bridge to definitive therapy or as a palliative procedure, with an acceptable mortality. BAV is associated with a significant improvement in symptoms and is valuable as a palliative treatment in high‐risk patients, where no other invasive option is available.

     

Percutaneous closure of post TAVR LV apical pseudoaneurysm

Left ventricular (LV) apical pseudoaneurysm is a well known complication of myocardial infarction and open heart surgery procedures, and has more recently been described after transapical transcatheter aortic valve replacement (TAVR). Since the natural history includes a high incidence of cardiac rupture and mortality in the 30–45% range within the first year after diagnosis, surgical repair has been the main therapy. More recently, LV pseudoaneurysms have been closed using percutaneous methods. We describe a post‐TAVR pseudoaneurysm for which closure was done via retrograde LV access using a vascular plug, and provide a review of recent literature on closure methods and outcomes. © 2015 Wiley Periodicals, Inc.     

Successful use of the loop snare technique for crossing a degenerated surgical valve with the Evolut‐R system

We first report the case highlighting a loop snare wire technique may be a useful percutaneous treatment option when faced with difficulty crossing the Evolut‐R system into a surgical valve due to interference between the two prostheses, especially in cases with a very horizontal aorta.     

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.     

Transcatheter aortic valve replacement in unicuspid aortic valve stenosis

Unicuspid aortic valve (UAV) offers unique challenges to transcatheter aortic valve replacement (TAVR), due to asymmetric expansion and apposition of the prosthesis during implantation. Although TAVR in bicuspid is now a well described experience, TAVR in unicuspid valve has not yet been described. A challenging case is described with TAVR in UAV using a Edwards Sapiens prosthesis via transapical approach. © 2016 Wiley Periodicals, Inc.     

Rebuttal: Percutaneous balloon dilation of severe pulmonary valve stenosis in patients with cyanosis and congestive heart failure

Transcatheter aortic valve implantation for bicuspid aortic valve stenosis (BAVS) is controversial, as its unfavorable anatomy may lead to device dislocation or malfunctioning. If device failure occurs, the bailout intervention can be more complex and technically challenging. We here report a unique case of late migration of a CoreValve (Medtronic, MN) implanted in a patient with BAVS, who was successfully treated with elective valve‐in‐valve implantation using the first valve as a firm scaffold after waiting for it to adhere at the migrated position. This new strategy may represent a useful salvage option for some patients with prosthesis migration. © 2015 Wiley Periodicals, Inc.     

Left-ventricular outflow tract ventricular-tachycardia event following CoreValve transcatheter aortic-valve implantation

We describe a patient with severe aortic stenosis who underwent CoreValve (Medtronic) implantation and presented several days later with a tachyarrhythmic episode. The electrocardiographic features of the arrhythmia were compatible with left-ventricular outflow tract ventricular-tachycardia. The life-threatening event was not associated with ischemia or an electrolyte disorder and was not drug-induced. A probable cause was the irritation of the myocardium by the prosthetic valve. Clinicians should be aware that the presence of anatomical parameters that increases the risk for myocardial injury and the need for pacemaker implantation might indicate an increased risk of a tachyarrhythmic episode.     

Delayed aortic dissection and valve thrombosis after transcatheter aortic valve implantation

We report a case of a 78‐year‐old female who presented with type A aortic dissection 22 months following transcatheter aortic valve implantation (TAVI). In addition, preoperative echocardiogram showed high gradients across the aortic prosthesis which was found to be thrombosed. At surgery, the intimal tear appeared to be non‐acute and anatomically related to the rim of the valve cage. The thrombosed valve was not replaced and the patient received anticoagulation therapy following surgery with significant improvement in valve gradients.     

Transapical tricuspid valve‐in‐ring implantation: An alternative approach to a challenging clinical scenario

We report on a transapical tricuspid valve‐in‐ring implantation performed via right ventricular apex using the Sapien‐XT‐prosthesis. A 57‐year‐old woman with recurrent episodes of right heart failure and three previous sternotomies, including tricuspid valve repair with a 32 mm Carpentier–Edwards–Classic annuloplasty ring was admitted due to recurrent severe tricuspid regurgitation. Given the excessive surgical risk, a 29 mm Sapien‐XT‐prosthesis was selected for valve‐in‐ring implantation. Transapical valve‐in‐ring implantation procedure was uneventful. Predischarge echocardiography showed only trace paravalvular tricuspid regurgitation in the septal region. Transapical approach via right ventricular apex is a viable alternative for tricuspid valve‐in‐ring implantation in selected high‐risk patients. © 2016 Wiley Periodicals, Inc.     

Comparison of acute elastic recoil between the SAPIEN‐XT and SAPIEN valves in transfemoral–transcatheter aortic valve replacement

• Complex arch anatomy (type 2, type 3) and bovine configuration were identified in 34.4% and 20.5% of carotid stent patients, respectively.
• Catheter manipulation time (CMT), rather than arch complexity per se, was the only independent predictor of adverse events after carotid stenting.
• Careful attention to patient selection, preprocedural planning, and stent technique are important to ensure success.

     

Overinflation of balloon-expandable valves for transcatheter treatment of pure noncalcified native aortic regurgitation: How much oversizing is needed and achievable?

Transcatheter aortic valve implantation (TAVI) in noncalcified pure aortic valve regurgitation is challenging as dedicated valves are not widely available. We present a case series of four inoperable patients who underwent compassionate TAVI for this indication at our institution with a balloon-expandable valve. In this context, we analyzed the relevant technical aspects such as the need for larger oversizing of the transcatheter prosthesis and the safety and limits of valve overexpansion.