J INVASIVE CARDIOL 2017;29(6):E65-E66.
Key words: TAVR, valve-in-valve, valve failure, Perceval device, sutureless
We present the case of a 75-year-old woman who had postoperative prosthetic valve failure with unusual imaging findings within a month after surgical implantation of a sutureless valve. The patient had undergone minimally invasive implantation of a medium-sized Perceval sutureless valve (Sorin) 3 weeks prior for severe calcific aortic stenosis (mean gradient, 51 mm Hg; peak velocity, 4.4 m/s; valve area, 0.8 cm2; normal left ventricular systolic function). Her immediate postoperative course was characterized by recurrent hospitalization for heart failure exacerbation with New York Heart Association class III symptoms. An intraoperative transesophageal echocardiogram (TEE) following surgical aortic valve replacement had demonstrated a well-seated prosthesis with no paravalvular leak or structural valve deformation. Her past medical history was significant for diabetes mellitus, chronic kidney disease stage III, heart failure with preserved ejection fraction, and paroxysmal atrial fibrillation. On physical examination, there was a 2/6 systolic ejection murmur best heard at right second interspace. TEE demonstrated mild-to-moderate anterior paravalvular regurgitation (PVR) from (suspected) incomplete valve expansion within the left ventricular outflow tract, resulting in high Doppler transvalvular gradient (mean gradient, 28 mm Hg; peak velocity, 3.4 m/s) (Video 1A). Cardiac magnetic resonance imaging demonstrated the site of (moderate) PVR with a deformed (kidney-shaped) valve prosthesis in the left ventricular outflow tract (Video 2B). Following a multidisciplinary heart team discussion, a decision was made to proceed with balloon aortic valvuloplasty (BAV) to “reshape” the Perceval valve prosthesis, with a valve-in-valve transcatheter aortic valve replacement (TAVR) planned as a bail-out strategy. A cardiac computed tomography scan (TAVR protocol) also demonstrated the deformed valve prosthesis without calcification, which may have contributed to its underexpansion (Figure 1).
The balloon sizing strategy for BAV was based on the size of the balloon utilized at the time of surgical Perceval valve prosthesis implantation (22 mm). Serial valvuloplasties with incremental balloon sizes (18 mm, 20 mm, and 23 mm) were performed with rapid ventricular pacing. While the valve remained deformed with 18 mm and 20 mm balloon inflations, a transient circular conformation was obtained following balloon valvuloplasty with a 23 mm balloon, but was lost almost instantaneously on balloon deflation due to recoil of the sinusoidal elements of the Perceval valve prosthesis (Video 3B and Video 4). We therefore proceeded with a valve-in-valve TAVR with a 20 mm Sapien 3 valve (Edwards Lifesciences) deployed transfemorally such that its proximal edge was well aligned with the commissural elements supporting the Perceval valve prosthesis (Video 3C). TEE demonstrated complete resolution of aortic insufficiency following TAVR, with resolution of transaortic gradient (peak and mean gradients of 13 mm Hg and 10 mm Hg before TAVR to 1 mm Hg and 2 mm Hg after TAVR, respectively) on hemodynamic assessment (Figure 2), and restoration of circular valve conformation on fluoroscopy (Video 3D).
Watch the associated Video Series here.
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From Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas and Weill Cornell Medical College, New York, New York.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Reardon reports consultant fees from Medtronic. The remaining authors report no conflicts of interest regarding the content herein.
Manuscript submitted November 9, 2016, provisional acceptance given November 11, 2016, final version accepted November 14, 2016.
Address for correspondence: Neal S. Kleiman, MD, Houston Methodist Hospital, 6565 Fannin Street, Houston, TX 77030. Email: firstname.lastname@example.org