Kissing Balloon "Valvuloplasty" of Obstructed Mechanical Aortic Valve: When You Are Running Out of Options.

We report an unusual case where "stuck" bileaflet aortic prosthetic valve occluders were partly released by performing emergency balloon dilatation with 2 noncompliant balloons by a percutaneous femoral approach. (Level of Difficulty: Advanced.).

A 76-year-old woman was admitted to hospital. She had previously undergone coronary artery bypass grafting with aortic valve replacement (AVR) and mitral valve replacement (MVR) with mechanical St Jude valves (Abbott) (#23 and #29, respectively) for rheumatic heart disease 14 years earlier. She had been asymptomatic until this admission. A week before admission, her warfarin had been replaced with enoxaparin before a bone marrow biopsy. Her international normalized ratio had decreased to 1.4. Two days later, she developed rapidly progressive dyspnea and was admitted.

Fluoroscopy demonstrated severe restriction of the AVR occluders (Figure 1A, Video 1) with normal MVR function (mean diastolic gradient on Doppler imaging had been 4 mm Hg). Systemic thrombolysis with tissue-type plasminogen activator (t-PA) produced no clinical or echocardiographic improvement. The patient declined reoperation and continued to deteriorate hemodynamically, with new, severe left ventricular (LV) impairment (ejection fraction [EF], 35%) resulting from afterload mismatch from the obstructed valve and with persistent hypotension.

Figure 1

Balloon Valvuloplasty of Bileaflet Prosthetic Aortic Valve

(A) Fluoroscopic en face view of bileaflet mechanical aortic prosthesis showing stuck occluders. (B) Simultaneous inflation of a 3.5-mm balloon centrally and a 6-mm balloon on the other side of the occluder. (C and D) Pre- and post-gradients on Doppler echocardiography. (E) Chest radiograph before percutaneous intervention showing pulmonary congestion. (F) Chest radiograph post–balloon intervention showing resolution of chest congestion.

With the patient under general anesthesia, we attempted percutaneous release of the disks after preprocedural bench testing of an identical bileaflet mechanical aortic valve prosthesis for accurate balloon sizing. A Sentinel cerebral protection device (Boston Scientific) was placed from the right radial artery, and an 8-F sheath was placed from the right femoral artery. A Sion angioplasty guidewire (Asahi Intecc) passed between the disks, and a 2.5-mm semicompliant balloon, followed by a 3.5-mm balloon, was inflated at 20 atm at multiple levels across and behind the valve occluders, thereby improving the motion of the anterior occluder. We delivered 20 mg of t-PA locally through the guide catheter, without improvement. We wired both sides of the stuck posterior occluder and then simultaneously inflated a 3.5-mm balloon centrally and a 6-mm balloon on the other side of the occluder to release it (Figure 1B, Videos 2 to 5). The peak velocity across the AVR decreased from 4.1 to 3 m/s (Figures 1C and 1D). Pulmonary edema resolved on the chest radiograph (Figures 1E and 1F), and this was accompanied by clinical improvement; there was no evidence of damage to the occluders on repeat echocardiography.

Thrombolysis is an accepted option for the treatment of obstructive thrombosis of prosthetic valves, but there was no improvement clinically or on imaging after its use systemically or locally in our patient. With emergency reoperation initially refused by the patient, valvuloplasty became the only intervention feasible in the context of worsening hemodynamic parameters and clinical deterioration. The success of this intervention allowed the LVEF to improve. The patient agreed to undergo redo valve replacement surgery, but she died of pneumonia and sepsis before that could be performed.

Funding Support and Author Disclosures

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