Combination of Double Chimney Technique and Prosthesis Post-Dilation After Valve-in-Valve Implantation.

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is an effective treatment for aortic bioprosthetic valve degeneration. ViV-TAVI could lead to coronary occlusion. We describe the case of a patient treated with double chimney technique to protect coronary ostia followed by post-dilation for high residual transvalvular gradient using "three-kissing balloon" approach. (Level of Difficulty: Advanced.).

We report a case of valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) for aortic valve bioprosthesis degeneration with high residual transvalvular gradient requiring both protection of coronary ostia and post-expansion of the prosthesis in an 83-year-old woman. She was admitted for dyspnea (New York Heart Association functional class III to IV) in March 2019. Eight years earlier, she underwent surgical aortic valve replacement with a 21-mm Mitroflow bioprosthesis (Sorin Group USA Inc., Arvada, Colorado) with a postprocedural mean gradient of 20 mm Hg. Echocardiography examination showed bioprosthesis degeneration with severe stenosis (aortic valve area 0.7 cm2, mean ΔP 51 mm Hg) and insufficiency with normal left ventricular function.

Angiographic examination revealed no coronary artery stenosis, low take off of coronary arteries, and severe aortic regurgitation (Video 1). Computed tomography scans showed a virtual transcatheter valve-to-coronary ostia distance of 4.9 and 4.2 mm from the right and the left coronary ostium, respectively, and a low take of coronary ostia (10 mm) (Figure 1A).

Figure 1

The “Double” Chimney and “Three-Kissing Balloon” Techniques

(A) Virtual transcatheter valve-to-coronary ostia distance measured during computed tomography. (B and C) Deployment of left main and right coronary artery stents. (D) Angiographic appearance of fully deployed Evolut R (Medtronic) 23 mm with coronary patency. (E) Simultaneous valve and stents post-dilation. (F) Final angiographic result.

Due to the high risk of reintervention and coronary occlusion, a ViV-TAVI in combination with coronary stent implantation on both coronary ostia was planned.

Two zotarolimus drug-eluting stents (4 × 22 mm) were positioned in left main and proximal right coronary artery with protrusion of about two-thirds of the stent’s length in the aortic root to cover the highest portion of the Mitroflow leaflets (Figures 1B and 1C). While maintaining stents in position, through right common femoral artery a 23-mm Medtronic Evolut-R valve (Medtronic, Inc., Minneapolis, Minnesota) was advanced across the surgical bioprosthesis and completely unscrewed after the deployment of both stents (Figure 1D, Videos 2 and 3).

A mean 45 mm Hg residual transprosthetic peak gradient was measured; a post-dilation with 20-mm balloon was performed with a final peak gradient of 20 mm Hg and no paravalvular leak. To prevent crushing of the stents during valve post-dilation, combined simultaneous inflation of balloons of the stents was performed with patency of coronary ostia (Figure1E and 1F, Videos 4 and 5).

The patient was discharged without symptoms with a mean residual transvalvular gradient of 15 mm Hg. No adverse events were reported at 1-year follow-up.

Coronary obstruction is a life-threatening complication that could occurs during ViV-TAVI procedure performed in degenerated surgical bioprosthesis, especially if associated with narrow sinotubular junction, narrow sinuses of Valsalva, valve-to-coronary ostia distance <4 mm, or coronary height <12 mm. Moreover, this risk is further increased when high gradients residues after ViV-TAVI and post-dilatation is necessary (1).

Different approaches to facilitate the ViV-TAVI procedure while preventing coronary occlusion and high residual transvalvular gradient, such as Basilica, bioprosthetic valve fracture, and chimney snorkel techniques, have been previously reported (2,3). However, to date, the application of preventive ostial coronary protection combined with post-dilatation of the new implanted valve for high residual transvalvular gradient has not been described.

To plan an effective procedure, it is important to perform a careful pre-procedural multimodal imaging assessment. In addition, the maintenance of the balloons from deployed stents after the release of the transcatheter valve is crucial to prevent coronary obstruction. Finally, if post-expansion of the prosthesis is required, the “three-kissing balloon” technique can be successfully adopted to prevent crushing of the coronary stents.

Author Disclosures

The authors have reported that they have no relationships relevant to the contents of this paper to disclose.