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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 49-51  

Transcatheter aortic valve replacement valve in transcatheter aortic valve replacement valve for severe periprosthetic regurgitation


Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA

Date of Submission24-Aug-2018
Date of Acceptance11-Sep-2019
Date of Web Publication23-Jan-2020

Correspondence Address:
Dr. Sneha Nandy
302, Lakefront Solitaire Powai, Mumbai - 400 076, Maharashtra, India

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HEARTVIEWS.HEARTVIEWS_92_18

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   Abstract 


The management of postprocedure severe aortic periprosthetic regurgitation after transcatheter aortic valve replacement (TAVR) is unknown. While valve-in-valve TAVR has been associated with favorable outcomes for degenerative surgically implanted bioprosthetic valves, there are no evidence-based guidelines for immediate TAVR valve in TAVR valve for periprosthetic regurgitation. We present a patient who underwent a TAVR valve in TAVR valve implantation within 48 h of her first procedure and showed a good response.

Keywords: Periprosthetic regurgitation, transcatheter aortic valve replacement, valve-in-valve


How to cite this article:
Nandy S, Wan SH, Klarich K. Transcatheter aortic valve replacement valve in transcatheter aortic valve replacement valve for severe periprosthetic regurgitation. Heart Views 2020;21:49-51

How to cite this URL:
Nandy S, Wan SH, Klarich K. Transcatheter aortic valve replacement valve in transcatheter aortic valve replacement valve for severe periprosthetic regurgitation. Heart Views [serial online] 2020 [cited 2020 Feb 24];21:49-51. Available from: http://www.heartviews.org/text.asp?2020/21/1/49/276539




   Introduction Top


The management of postprocedure severe aortic periprosthetic regurgitation after TAVR is unknown.


   Case Presentation Top


A 79-year-old female with symptomatic severe aortic stenosis with the intermediate surgical risk presented to the hospital with 1 year of progressive shortness of breath. Past medical history was significant for hypertension and coronary artery disease. Her echocardiogram showed a mean gradient of 42 mmHg and aortic valve area of 0.93 cm 2. She underwent a transfemoral, transcatheter aortic valve replacement (TAVR) with a 23-mm Sapien S3 valve and intraoperative systolic mean gradient decrease to 6 mmHg.

However, the patient's symptoms did not improve and a repeat transthoracic echocardiogram postoperative day 1 revealed significant moderately-severe aortic periprosthetic regurgitation with multiple jets [Figure 1]. The next day, she underwent 25-mm Edwards Sapien balloon dilation of prior TAVR without improvement in aortic insufficiency. She then received a successful TAVR valve-in-TAVR valve with an additional 23-mm Sapient S3, with improvement in hemodynamics and symptoms [Figure 2] and [Figure 3].
Figure 1: Moderate-to-severe periprosthetic regurgitation following the first transcatheter aortic valve replacement

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Figure 2: Mild residual regurgitation following transcatheter aortic valve replacement valve in transcatheter aortic valve replacement valve implantation

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Figure 3: Three-dimensional image postimplantation of transcatheter aortic valve replacement valve in transcatheter aortic valve replacement valve

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   Discussion Top


Transcatheter aortic valve replacement (TAVR) has become an alternative to surgical aortic valve replacement for inoperable or high-risk patients with severe aortic stenosis.[1] Postprocedure periprosthetic regurgitation is seen in approximately 70% of all patients who undergo TAVR and is graded as moderate or severe in approximately 15%.[2]

This regurgitation may be valvular due to prosthetic leaflet dysfunction or paravalvular due to a poor annular sealing.[3] Since paravalvular regurgitation negatively affects the prognosis after TAVR in patients with more than mild periprosthetic aortic regurgitation (PAR), this procedure-related complication has to be addressed to further improve the outcome of patients after TAVR.[4],[5]

Our patient had acute heart failure after the first transcatheter heart valve (THV) from multiple regurgitant jets. Balloon dilation of this THV was attempted but unsuccessful in improving the regurgitation. While valve-in-valve TAVR has been associated with favorable outcomes for degenerative surgically implanted bioprosthetic valves, there are no evidence-based guidelines for immediate TAVR valve in TAVR valve for periprosthetic regurgitation. In addition, there are limited data available on long-term outcomes of a TAVR valve in TAVR valve.

There is evidence to suggest that THV-in-THV implantation is a viable treatment strategy to reduce significant PAR in malpositioned THVs with too shallow (i.e., implanted predominantly in the aorta) or too deep (i.e., implanted predominantly in the left ventricle) implantation of the prosthesis. The second valve can be deployed in a way that the sealing pericardial skirts of both valves overlap and that the second valve ensures sealing with the native valve annulus.[3]

In contrast to open-heart surgery, TAVR does not offer the opportunity to measure the aortic annulus under direct vision during the procedure. Therefore, the dilemma before each TAVR procedure is the appropriate sizing of the dimensions of the aortic annulus and to choose not only the size but also the THV type (self-expanding vs. balloon-expandable) that fits the given anatomy best.[2]

In the case of our patient, we used the same size THV for the second procedure (23-mm Edwards Sapien) as well as route of access (i.e. transfemoral). Postimplantation of the second THV, the patient's symptoms and hemodynamics improved with only mild residual periprosthetic regurgitation.

This case highlights that TAVR valve-in-TAVR valve implantation for failed balloon-expandable TAVR is feasible and may result in satisfactory outcomes.


   Conclusion Top


TAVR valve in-TAVR valve may be an option with favorable outcomes for immediate periprosthetic regurgitation following TAVR procedure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, et al. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med 2010;363:1597-607.  Back to cited text no. 1
    
2.
Sinning JM, Vasa-Nicotera M, Chin D, Hammerstingl C, Ghanem A, Bence J, et al. Evaluation and management of paravalvular aortic regurgitation after transcatheter aortic valve replacement. J Am Coll Cardiol 2013;62:11-20.  Back to cited text no. 2
    
3.
Toggweiler S, Wood DA, Rodés-Cabau J, Kapadia S, Willson AB, Ye J, et al. Transcatheter valve-in-valve implantation for failed balloon-expandable transcatheter aortic valves. JACC Cardiovasc Interv 2012;5:571-7.  Back to cited text no. 3
    
4.
Rodés-Cabau J. Transcatheter aortic valve implantation: Current and future approaches. Nat Rev Cardiol 2011;9:15-29.  Back to cited text no. 4
    
5.
Webb JG, Wood DA. Current status of transcatheter aortic valve replacement. J Am Coll Cardiol 2012;60:483-92.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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