Transcatheter Aortic Valve Replacement Valve in Transcatheter Aortic Valve Replacement Valve for Severe Periprosthetic Regurgitation.

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. Copyright:

INTRODUCTION

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

CASE PRESENTATION

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 cm2. 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 [Figures 2 and 3].

Figure 1

Moderate-to-severe periprosthetic regurgitation following the first transcatheter aortic valve replacement

Figure 2

Mild residual regurgitation following transcatheter aortic valve replacement valve in transcatheter aortic valve replacement valve implantation

Figure 3

Three-dimensional image postimplantation of transcatheter aortic valve replacement valve in transcatheter aortic valve replacement valve

DISCUSSION

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.[45]

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

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.