Clinical Images

Technical Considerations for TAVR in the Treatment of Stentless Bioprosthetic Aortic Valve Insufficiency in LVAD Patients

Jonathan Yap, MBBS, MRCP, MPH1,2; Benjamin R. Stripe, MD1; Garrett B. Wong, MD1; Thomas W. Smith, MD1; Jeffrey A. Southard, MD1

Jonathan Yap, MBBS, MRCP, MPH1,2; Benjamin R. Stripe, MD1; Garrett B. Wong, MD1; Thomas W. Smith, MD1; Jeffrey A. Southard, MD1

J INVASIVE CARDIOL 2020;32(6):E174.

Key words: cardiac imaging, transcatheter aortic valve replacement


An 80-year-old man with a history of bicuspid aortic valve (AV) complicated by severe aortic insufficiency (AI) was treated with a 29 mm Toronto Free-style (Medtronic) root and valve replacement 15 years ago. He developed a non-ischemic cardiomyopathy requiring continuous-flow left ventricular assist device (LVAD) implantation as destination therapy 2 years ago. He presented with progressive New York Heart Association class III symptoms and severe bioprosthetic AV insufficiency (Figures 1A and 1B; Video 1). Transcatheter aortic valve replacement with a 26 mm Sapien 3 valve (Edwards Lifesciences) was planned via the transfemoral approach under general anesthesia and transesophageal echocardiographic guidance. 

We encountered several technical challenges. First, the stentless Freestyle root/valve has no radiopaque markers, with the reimplanted coronaries often low lying (Figure 1C). As such, the left coronary was wired pre-emptively and balloon predilation of the AV was performed to assess the risk of coronary occlusion (Figure 1D; Video 2). A pigtail catheter was positioned at the annulus with concomitant contrast injection to aid in positioning the valve. The valve was positioned slightly lower, with the central marker at annular level, as the sewing ring of this valve is at the base (Figure 1E; Video 3). Second, there was concern for valve embolization due to lack of calcification in the setting of AI as well as constant suction from the LVAD. The sewing ring of the Freestyle valve often incites a fibrotic response, providing sufficient resistance to allow the valve to anchor. During valve deployment, the LVAD flow can be temporarily reduced or turned off to prevent valve embolization/movement during deployment. The TAVR procedure was successfully performed without coronary obstruction or valve embolization. At 2-month follow-up, the valve was stable and the patient reported significant symptomatic improvement.

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From the 1Division of Cardiovascular Medicine, University of California Davis, Sacramento, California; and 2National Heart Centre Singapore, Singapore.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted October 23, 2019.

Address for correspondence: Jeffrey A. Southard, MD, UC Davis Medical Center, 4860 Y Street, Suite 2820, Sacramento, CA 95817. Email: jasouthard@ucdavis.edu

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