Degenerated Suturless Perceval with (Paravalvular Leak and AS) Treated by Valve in Valve using S3 Edward Valve.

A 70-year-old female patient, known to be diabetic and hypertensive, was diagnosed with coronary artery disease and severe aortic stenosis aortic valve area 0.5 cm, peak gradient of 110 mmHg, mean gradient 55 mmHg). This patient underwent coronary artery bypass graft with two grafts and artery bypass grafting in 2012. She received a sutureless Perceval aortic valve with good postoperative results except for a small jet of paravalvular leak. She did well for 5 years until she began experiencing dyspnea on exertion. The patient was found to have moderate to severe aortic regurgitation and moderate aortic stenosis which progressed over the years with multiple admissions for heart failure and pulmonary edema. The patient was considered high risk for operative treatment. Therefore, she was treated by percutaneous valve-in-valve technique using S3 Edward valve with excellent results. Copyright:

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) procedures are becoming more popular in the last 10 years worldwide. It is now considered a common Cath lab procedure in most countries.

The degeneration of prosthetic tissue valves is a very well-known phenomenon, which may result in aortic stenosis, aortic regurgitation, or combined valve pathology.

The same mechanism of degeneration may occur when the surgeons use sutureless valves in surgical aortic valve replacement (SAVR). We propose a possible treatment of such patients by using TAVI and Valve-in-Valve (ViV) technique.

CASE PRESENTATION

A 70-year-old female patient, known to be diabetic and hypertensive, was diagnosed with coronary artery disease, and severe aortic stenosis (AVA 0.5 cm, Peak gradient of 110 mmHg, Mean gradient 55 mmHg). In 2012, this patient underwent coronary artery bypass graft with two grafts and artery bypass grafting. She received a sutureless Perceval valve of medium size [Figure 1], with good postoperative results despite a small jet of Paravalvular Leak (PVL) which was seen at the anterior aspect. The Aortic valve showed a peak gradient of 27 mmHg and a mean gradient of 13 mmHg.

Figure 1

Perceval is the 100% sutureless valve for aortic valve replacement, with the unique characteristic of allowing sutureless positioning and anchoring at the implant site

She did well over 5 years until she began experiencing more dyspnea on exertion. The patient was found to have moderate aortic regurgitation and moderate aortic stenosis [Figure 2], which progressed over the years with multiple admissions for heart failure and pulmonary edema. The case was investigated, a coronary and graft angiogram was done. The left mammary artery graft to left anterior descending artery was patent and the saphenous vein graft to obtuse marginal was also patent.

Figure 2

Echo Doppler shows aortic stenosis with PG 58 mmHg and PG 30 mmHg with moderate AR

Echocardiogram findings have shown the following: Normal ejection fraction, moderate aortic regurgitation with PVL [Figure 3], moderate to severe aortic stenosis with aortic valve (AV)-peak gradient of 80 mmHg and a mean Gradient 35 mmHg.

Figure 3

Showed an anterior paravalvular leak (moderate AR)

This case was discussed in the heart team meeting, and she was labeled as high risk for operative treatment. Risks and benefits were explained to the patient and her family.

The patient underwent a TAVI procedure through the right femoral approach [Figure 4]. We used the ViV technique. According to the original valve size, our computed tomography-scan measurement, and sizing an S3 size 26 mm. Edward valve was deployed with excellent final results [Figures 5 and 6]. The echocardiogram showed no PVL and the gradient was 15 mmHg [Figure 7]. The patient was discharged from hospital after 2 days in a very good condition.

Figure 4

Showed a Perceval (Sutureless valve) by fluoroscopy

Figure 5

Showed A valve in valve deployment, using an Edward S3 during balloon inflation

Figure 6

Showed a final result of valve-in-valve deployment (S3 Edward valve inside the sutureless valve)

Figure 7

Showed a final result of valve in valve, color Doppler with paravalvular leak

DISCUSSION

TAVI, has become more popular in the last decade as an alternative to surgical aortic valve replacement for high risk patients with severe symptomatic aortic stenosis. Recently, TAVI is debated in replacing surgery for both intermediate and low-risk patients.[1]

This new technology of sutureless (self-expandable aortic valve), has been adopted by some cardiac surgeons as an alternative to the conventional bioprosthetic aortic valve replacement,[2] because surgeons prefer decreasing the cross-clamp time and shortening cardiopulmonary bypass time, and the sutureless valve may achieve better hemodynamic parameters.[34]

This new procedure was utilized by a small number of cardiac surgeons in the Middle East. In our cardiac center, about 90 cases were done over the last 8 years. We monitored those patients with regular follow-up visits in the cardiac clinics and echocardiography studies.[5] In our center, we noticed so far two cases of symptomatic degeneration of Perceval valve, one is this patient, and the second is a lady with moderate PVL with controlled symptoms on optimal medical therapy.

In general, surgical aortic bioprosthetic valves show degeneration over time, which could result in either aortic stenosis, aortic regurgitation, or a combination of both lesions. This may occur over a period of 7–10 years in most cases. Most of such patients may require subsequent interventions.[67]

Since the start of the TAVR program, the ViV option was used during percutaneous procedures for the treatment of PVL due to either low or high positioned valve. Nowadays, the aortic ViV technique is accepted, and became a routine procedure. This method was approved by the FDA as a percutaneous procedure for the treatment of degenerated failed bioprosthetic valves, mainly in patients with a high surgical risk.[8] The ViV technique was used also for the treatment of degenerated homografts. Many recent new studies showed that TAVI is superior to medical therapy in high-risk inoperable patients, due to the increase in survival rate and the cost-effectiveness using this procedure.[910]

Regarding ViV technique for degenerated sutureless (Perceval), the number of cases done by this method is small, and the long-term benefit is unknown. Because of the difference in structure, such as a large nitinol stent with a soft ring, this may lead to less support for an additional device inside this type of valve.[1112]

Most of studies and case reports about treating degenerated surgical aortic bioprosthetic valve using (ViV) technique originated from Western countries. We are lacking similar data from Middle East countries. We describe here our first degenerated sutureless valve in our cardiac center, this patient was treated successfully with the ViV technique. The patient was discharged in a very good condition and had two follow up visits so far.

CONCLUSION

TAVI procedure has become a regular and safe procedure in the Cardiac Cath Lab as reported in major clinical trials. It is now approved to treat degeneration of aortic bioprosthetic valve by ViV technique. The new surgical technique of using sutureless valves is feasible. If the same phenomenon of degeneration would happen with this type of valve, ViV technique may be the optimal treatment of choice.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.