Journal of Invasive Cardiology

From the Department of Cardiology, Rigshospitalet, Copenhagen, Denmark.

The authors report no conflicts of interest regarding the content herein.

Manuscript submitted March 5, 2009, provisional acceptance given April 30, 2009, and final version accepted May 4, 2009.

Address for correspondence: Lars Søndergaard, Department of Cardiology B 2014, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark. E-mail: lars.sondergaard@rh.dk

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ABSTRACT: Transcatheter aortic valve implantation (TAVI) in severe aortic stenosis has proven to be a feasible and effective treatment modality for inoperable patients. Until now, neither aortic regurgitation nor degenerated bioprostheses has been an indication for TAVI. However, this article reports a successful valve-in-valve implantation of a CoreValve aortic valve prosthesis through the right subclavian artery in a case of severe aortic regurgitation within a degenerated aortic homograft. The case exemplifies the possibilities of expanding the indications for TAVI, as well as other vascular access options than the femoral arteries.

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J INVASIVE CARDIOL 2009;21:E197–E200

Transcatheter aortic valve implantation (TAVI) has proven to be a safe, efficient new treatment option for inoperable patients with severe symptomatic aortic stenosis (AS). In 1992, Andersen and colleagues made an early attempt at transcatheter delivery of a valve in the aorta in a porcine model,1 and since then, two systems for aortic valve positioning have been introduced: the self-expanding CoreValve ReValving® System (Medtronic CV Luxembourg Sarl) prosthesis and the balloon-expandable Edwards SAPIEN™ transcatheter aortic heart valve prosthesis (Edwards Lifesciences, LLC, Irvine, California). Contemporary results are promising, with a considerable increase in aortic valve area and a decrease in the peak pressure gradient across the aortic valve. Most of all, there is substantial relief of symptoms such as dyspnea and angina.2

The current recommended treatment criteria for the two prosthetic systems do not include patients with degenerated bioprostheses or patients with aortic regurgitation (AR).2

This article presents the case of a valve-in-valve procedure in which a CoreValve prosthesis was inserted through the right subclavian artery into a 10-year-old degenerated aortic homograft with severe AR.

Case Description

The patient was an 86-year-old male who, in 1997, had undergone urgent cardiac surgery due to Type-A aortic dissection with implantation of a composite graft consisting of a 25 mm Björk Shiley mechanical aortic valve (Shiley, Inc., Irvine, California) and a 28 mm Vascutec vascular tube. In 1998, the mechanical aortic valve was infected with Staphylococcus epidermidis. Initially, the patient was treated with vancomycin and rifampicin, but after 3 weeks of treatment, he developed a severe allergic reaction with universal maculopapulous exanthema. Antibiotic treatment was put on hold for 1 week until the exanthema diminished, and was then re-established with erythromycin and rifampicin for 6 and 4 weeks, respectively. Due to positive blood cultures despite antibiotic treatment, it was decided to replace the mechanical valve with a 23 mm aortic homograft bioprosthesis with preservation of the vascular tube.