Reversible thrombotic aortic valve restenosis after valve‐in‐valve transcatheter aortic valve replacement

Thrombotic aortic valve restenosis following transcatheter aortic valve replacement (TAVR) has not been extensively reported and the rates of TAVR valve thrombosis are not known. We present three cases of valve‐in‐valve (VIV) restenosis following TAVR with the balloon expandable transcatheter heart valves, presumably due to valve thrombosis that improved with anticoagulation. © 2016 Wiley Periodicals, Inc.     

First report of a simultaneous transcatheter mitral valve‐in‐valve and aortic valve replacement in a left ventricular assist device patient

Transcatheter aortic valve replacement is standard of care for patients with severe aortic stenosis at high risk for surgical aortic valve replacement. Although not intended for treatment of primary aortic insufficiency, several transcatheter aortic valve prostheses have been used to treat patients with severe aortic insufficiency (AI), including patients with left ventricular assist devices (LVAD), in whom significant AI is not uncommon. Similarly, transcatheter valve replacements have been used for valve‐in‐valve treatment, in the pulmonary, aortic, and mitral positions, either via a retrograde femoral approach or antegrade transseptal approach (mitral valve‐in‐valve). In this case report, we report an LVAD patient with severe aortic insufficiency and severe bioprosthetic mitral prosthetic stenosis, in whom we successfully performed transfemoral aortic valve replacement and transfemoral mitral valve‐in‐valve replacement via a transseptal approach. © 2017 Wiley Periodicals, Inc.     

Fracture of small Mitroflow® aortic bioprosthesis following valve‐in‐valve transcatheter aortic valve replacement with ACURATE neo valve—From bench testing to clinical practice

Valve‐in‐valve (ViV) transcatheter procedures have emerged as a feasible, less‐invasive treatment option for bioprosthetic structural valve deterioration. However, in the presence of a small bioprosthesis, a significant residual gradient after ViV procedures often occurs and has been associated with poorer clinical outcomes. We report the use of the self‐expandable supra‐annular ACURATE neo? valve to treat degenerated Mitroflow (Sorin) aortic bioprosthesis with severe residual elevated gradients followed by valve fracture with a postdilation using a noncompliant balloon leading to significant reduction in residual gradients. In conclusion, the use of ACURATE neo? valve followed by the controlled fracture of the surgical bioprosthesis frame with a noncompliant balloon is a safe and effective approach for patients with Mitroflow® failing valves and residual elevated gradient after transcatheter aortic valve replacement.     

Emergent transcatheter mitral valve‐in‐valve implantation in a patient with cardiogenic shock secondary to a failed mitral bioprosthesis

Transcatheter valve‐in‐valve (VIV) implantation is emerging as a therapeutic option for treatment of failed bioprosthesis in patients that are deemed high‐risk or inoperable for redo‐valve replacement. It can be carried out in suitable bioprosthetic valves in any position and usually performed as an elective or semi‐elective procedure. Here, we report a case of emergent transcatheter VIV implantation in a failed mitral bioprosthesis in a critically ill patient with cardiogenic shock. We conclude that transcatheter VIV implantation may also be an option for critically ill patients with failing bioprosthesis. © 2015 Wiley Periodicals, Inc.     

Simultaneous transapical aortic and mitral valve‐in‐valve implantation for double prostheses dysfunction: Case report and technical insights

Transcatheter “Valve‐in‐Valve” implantation (ViV) has shown promising results in high‐risk patients suffering from structural valve deterioration (SVD) of a previously implanted heart valve bioprosthesis. We present a case of a 68‐year‐old woman with a history of three previous cardiac operations on the aortic and mitral valve. At the time of admission she was severely symptomatic due to a simultaneous SVD of a 23 mm aortic and of a 29 mm mitral St. Jude Biocor bioprosthesis. Because of the history of several cardiac operations and to her comorbidities, the patient was considered with an extremely high surgical risk profile and was therefore scheduled for double concomitant mitral and aortic ViV. Through a trans‐apical approach, the patient underwent 23 and 29 mm Edwards Sapien XT implantation in the aortic and mitral bioprosthesis, respectively. The procedure was uneventful as well as the following hospital stay. At 6‐months follow‐up the patient is in NYHA class I. Echocardiography shows that the aortic bioprosthesis has no leak and the mean gradient is 20 mm Hg while the mitral valve has mild leak and maximum and mean gradients are 21 and 10 mm Hg, respectively. The three main technical aspects that should be carefully considered in double concomitant ViV are: sequence of valve deployment (whether to implant the mitral or the aortic valve first), choice of access and valve sizing. In conclusion, double simultaneous trans‐apical mitral and aortic ViV is technically feasible. © 2014 Wiley Periodicals, Inc.     

First‐in‐human valve‐in‐valve implantation of a 20 mm balloon expandable transcatheter heart valve

An 86‐year‐old lady with recurrent admissions for heart failure due to a severely regurgitant aortic bioprosthesis (SJM Epic 19 mm) was not a candidate for re‐operation due to age and frailty. Her small ilio‐femoral arteries precluded a transfemoral transcatheter valve‐in‐valve (VIV) approach. The small internal diameter of her bioprosthesis (16 mm) forbids the implantation of the smallest available transapical transcatheter heart valve (THV). We, therefore, decided to perform a first‐in‐human transapical aortic VIV implantation using a 20 mm balloon expandable THV and a transfemoral delivery system. The procedure was successfully performed under general anesthesia, without any contrast dye and under fluoroscopy as well as transesophageal echocardiography guidance. The post‐procedural transvalvular gradient was 15 mm Hg (pre‐procedural 14 mm Hg). At 30‐day follow‐up, the lady was living independently at home without shortness of breath during her daily activities. If redo‐surgery for prosthetic regurgitation is not an option, VIV implantation in very small surgical bioprosthesis is feasible and leads to acceptable hemodynamics and clinical improvement.© 2012 Wiley Periodicals, Inc.     

Successful percutaneous paravalvular leak closure followed by transfemoral aortic lotus valve‐in‐valve implantation in a degenerated surgical bioprosthesis

Bioprosthesis degeneration is a relevant clinical issue that is increasingly developing with the higher expectancy of life. Its treatment may be further complicated by the presence of paravalvular leaks, which are usually consequence of tissue friability, annular calcification, and infection. The surgical treatment of such complex conditions may be too risky, so percutaneous techniques in selected centers are becoming an attracting option. We report the case of a 65‐year‐old gentleman with a previous aortic valve replacement (Perimount n.25) who was admitted with worsening heart failure and transoesophageal evidence of severe intraprosthetic regurgitation and a large paravalvular leak. Since he was judged at too high risk for surgery, he was treated by a fully percutaneous approach. First, he had his large paravalvular leak closed by implantation of two plugs from both retrograde and anterograde routes (arterial–venous loop created). After one month, he underwent a “valve‐in‐valve” transcatheter aortic valve implantation with a fully repositionable Lotus 23 mm valve, which was able to restore a completely normal aortic valve function and let to a dramatic improvement of his functional status at 6‐month follow‐up (from NYHA IV to NYHA I), when a transthoracic echocardiogram also confirmed the absence of any aortic regurgitation. This case shows how a tailored step‐by‐step fully percutaneous strategy is safe and feasible in high‐risk patients with both bioprosthesis degeneration and large paravalvular leaks. This novel opportunity would need to be better evaluated in properly addressed long‐term clinical studies. © 2016 Wiley Periodicals, Inc.     

“Valve‐in‐valve” for the treatment of paravalvular leaks following transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is commonly associated with some degree of aortic regurgitation (AR) secondary to the presence of paravalvular leaks. We present the case of an 86‐year‐old woman diagnosed with severe aortic stenosis who underwent TAVI with a 23‐mm Edwards‐SAPIEN valve. The procedure complicated with a severe paravalvular leak following TAVI that was unresponsive to balloon postdilation. This complication was successfully managed with the implantation of a second valve of the same diameter within the first one (“valve‐in‐valve”) resulting in trivial residual AR and the absence of significant transvalvular gradient at the end of the procedure. © 2009 Wiley‐Liss, Inc.     

The valve‐in‐valve technique: Transcatheter treatment of aortic bioprothesis malposition

Percutaneous aortic valve replacement is an emerging alternative to palliative medical therapy for nonsurgical patients with severe aortic valve stenosis. The impossibility of repositioning of the current transcatheter prosthesis in case of suboptimal placement is the main limit of these devices. Here, we report on a case of an 84‐year‐old woman successfully treated with implantation of two 18‐Fr CoreValve® prosthesis (CoreValve®, Irvine, California), because of the suboptimal deployment of the first one, analyzing the procedural technique and the immediate and short‐term clinical and hemodynamic results. © 2009 Wiley‐Liss, Inc.     

Valve‐in‐valve transcatheter aortic valve implantation with CoreValve/Evolut R© for degenerated small versus bigger bioprostheses

Objectives

We present our single center experience with Medtronic CoreValve and Evolut R regarding procedural outcome and 3 years follow‐up in patients with degenerated bioprostheses.

Methods

From 1645 patients who underwent transfemoral TAVI at our institution between February 2009 and December 2016, 37 patients with degenerated bioprosthesis were treated with Medtronic CoreValve/Evolut R. All data concerning baseline characteristic, procedural outcomes and follow‐up were entered into a dedicated database.

Results

Mean age was 83.9 ± 4.4 years and patients showed an average logistic EuroSCORE of 33.2 ± 16.7%. Successful ViV deployment was achieved in all cases, a permanent pacemaker was implanted in 16.2%, no periinterventional stroke and no coronary obstruction occurred. Mortality at 30 days was 2.7%, at 1‐year follow‐up 5.7% and at three years 13.5%. Depending on bioprosthesis size <23 mm versus ≥23 mm echocardiographic mean gradients post implantation were significantly higher in the smaller bioprostheses, 22.8 mmHg ± 9.4 mmHg versus 15.1 ± 7.1, P = 0.013.

Conclusion

ViV‐TAVI with CoreValve/R is demonstrated to be safe and effective in terms of no coronary obstruction and very low mortality up to 3 years despite slightly higher mean transprosthetic gradients especially in very small bioprostheses.

     

First percutaneous transcatheter aortic valve‐in‐valve implant with three year follow‐up

Objectives: This study was conducted to report the clinical, hemodynamic, and iconographic outcomes of the longest survivor of the global CoreValve experience. Background: Early results of percutaneous heart valve (PHV) implantation for severe symptomatic aortic stenosis (AS) have been encouraging, with mid term survival up to 2 years; however longer durability term is unknown. Although a PHV has been implanted in a degenerated surgical bioprosthesis, the feasibility of a PHV‐in‐PHV has not been demonstrated. Methods: A patient with severe refractory heart failure due to severe aortic regurgitation (AR) and moderate AS, underwent CoreValve prosthesis implantation. The PHV was deployed too proximal into the left ventricular outflow tract, resulting in severe AR through the frame struts. Using the first PHV as a landmark, a second CoreValve was then deployed slightly distal to the first, with trivial residual paravalvular leak. Results: The second CoreValve expanded well with proper function. Transvalvular gradient was 8 mmHg. Both coronary ostia were patent. New mild to moderate mitral regurgitation occurred due to impingement of the anterior mitral leaflet by the first PHV. NYHA functional class improved from IV to II, maintained over the past 3 years. Echocardiography at 3 years showed normal functioning CoreValve‐in‐CoreValve prostheses, without AR or paravalvular leaks. Transvalvular gradient was 10 mmHg. Cardiac CT showed stable valve‐in‐valve protheses with no migration. Conclusion: The CoreValve prosthesis has maintained proper function up to 3 years, with no structural deterioration or migration. Treating mixed aortic valve disease with predominant AR is feasible. The concept as well as durability of the first PHV‐in‐PHV has also been demonstrated. © 2008 Wiley‐Liss, Inc.     

First transcatheter valve‐in‐valve implantation in an apicoaortic conduit

Apicoaortic conduit surgery is an option for treating severe aortic stenosis. The implanted conduit valve may eventually fail and require replacement; this is usually performed by repeat surgery. Treating the conduit valve with a standard transcatheter heart valve is an option that has become feasible in recent years. We describe a case of a failed 23 mm CE bioprosthesis that was successfully treated with a 23 mm Sapien XT valve as a valve‐in‐valve procedure. © 2017 Wiley Periodicals, Inc.     

Perceval sutureless valve migration treated by valve‐in‐valve with a CoreValve Evolut Pro

In the last years, the use of sutureless devices in frail patients with severe aortic stenosis has increased thanks to their “easier and faster” technique of implantation in comparison to conventional surgery. Results from metanalysis show comparable outcomes in comparison to transcatheter aortic valve replacement (TAVR) in terms of mortality, stroke incidence, and rate of pace‐maker implantation. The incidence of para‐valvular leak (PVL) is even lower for sutureless devices than for TAVR. The few cases described are generally due to incomplete decalcification or incorrect valve sizing and consequent stent distortion. To our knowledge this is the first case describing PVL with massive aortic regurgitation due to early partial embolization of a Perceval valve and its successfully treatment with valve‐in‐valve by using a self‐expanding TAVR device.     

Transcatheter mitral valve‐in‐valve implantation in a pediatric patient

An 11‐year‐old girl, with 25 mm mosaic tissue valve presented with clinical and echocardiographic appearance of stenotic mitral valve prosthesis. Her condition was treated via a transcatheter valve‐in‐valve implantation using a 23 mm Edwards Sapien 3, with satisfactory outcome.     

Simultaneous transcatheter pulmonary and tricuspid valve‐in‐valve implantation for the treatment of failing pulmonary and tricuspid bioprostheses

We report a case of a patient with a history of bioprosthetic pulmonary and tricuspid valve replacement who developed significant stenosis and regurgitation of the bioprosthetic valves. Due to multiple comorbidities, he was deemed high risk for redo‐valve replacement surgery. He subsequently underwent percutaneous transcatheter pulmonary and tricuspid valve‐in‐valve procedure at the same setting. This is the first of such that is reported in the literature. © 2015 Wiley Periodicals, Inc.