Transcatheter aortic valve implantation for severe pure aortic regurgitation: looking beyond the image.

To the Editor,

The growing worldwide experience with TAVI has given rise to several off-label indications. Pure severe native aortic valve regurgitation without aortic stenosis is one of these off-label indications. However, clinical experience is limited worldwide (1-3). The results of this limited experience showed that although it is feasible in patients ineligible for surgery, there are many technical difficulties to overcome. Large annulus size and absence of calcification may cause reduced fixation of the valve at the annulus during deployment. In addition, the increased frequency of requiring two valves and leaving a significant residual aortic regurgitation are important concerns of the procedure (4, 5).

Awareness of technical difficulties and knowing tips to overcome these will help operators to have better procedural outcomes in such patients.

In this report, we aimed to mention our TAVI experience and some specific technical issues that were encountered in a pure severe aortic regurgitation patient; this was the first case in Turkey. The patient was an 85-year-old man with a severely dilated left ventricle and EF of 40%. The aortic valve was tricuspid and minimally calcified. The patient had several concomitant diseases and a high surgical risk that the off-label application of TAVI was decided. Cardiac CT revealed an annulus with 25.9 x 31.2 mm dimensions, which were in the upper limit for available prostheses. During the procedure, a 31-mm CoreValve prosthesis dislocated into the aorta in the first attempt. The prosthesis was successfully retrieved and reloaded. In the second attempt, the implantation was aimed at a slightly deeper position. The lower 2/3rd portion of the device was unfolded in the first step enabling prosthetic valve function. At this step, prosthesis did not obtain the expected coaxial alignment. The fluoroscopic image suggested a malopposed valve. Despite this image, the hemodynamic profile unexpectedly got better with prominent dicrotic notches on aortic pressure tracing. Relying on this hemodynamic evidence of properly functioning aortic valves, we continued deploying the upper 1/3rd portion of the device. After full deployment and release of the prosthesis, both fluoroscopic and hemodynamic images were perfect with no residual AR. A control after 6 weeks showed the stable position of the prosthesis with no paravalvular regurgitation.

This case demonstrates the importance of hemodynamic monitoring during TAVI. In a very critical step, we conducted the procedure by hemodynamic guidance rather than a sole fluoroscopic guidance, which yielded a perfect procedural outcome. This phenomenon has never been described in previous literature. We think that in such technically demanding patients in whom the optimal fluoroscopic positioning of the prosthesis is not always possible, the operator should take into account the hemodynamic profile and aortic pressure tracing of the patient to evaluate the functioning of the valve in that position. If the hemodynamic signs are in favor, neglecting an acceptable amount of fluoroscopic malposition would not result in a bad procedural outcome. Operators should keep in mind that hemodynamic monitoring must be a part of the procedure and may be a sign of proper valve positioning.