Valve in Valve Transcatheter Aortic Valve Replacement with Bioprosthetic Valve Fracture

- Operator : David Joel Cohen

Valve in Valve Transcatheter Aortic Valve Replacement with Bioprosthetic Valve Fracture
- Operators: David J. Cohen, MD, Seung-Jung Park, MD
Case Presentation
A 71 year-old female was admitted with dyspnea, NYHA functional class II and chest discomfort. She underwent dual valve replacement in 2007 with Biocor epic 21mm bioprosthetic aortic valve (AV) and Biocor epic 29mm bioprosthetic mitral valve. There was no significant coronary artery stenosis on the coronary CT angiogram. Electrocardiography showed normal sinus rhythm. Her STS score was 2.56.
Echocardiographic Findings
  1. Transthoracic echocardiography showed high pressure gradient of bioprosthetic AV with normal LV systolic function (EF=65%). AV area by continuity equation was 0.66 cm©÷. Maximal trans-AV flow velocity was 3.5 m/s. Mean and peak pressure gradient were 50 and 30 mmHg, respectively. There was mild stenotic component in prosthetic mitral valve with mitral valve area by pressure half time of 2.0cm2.
  2. Transesophageal echocardiography showed suspicious subaortic soft tissue growing which is suggestive of pannus formation.
CT Findings
  1. Aortic bioprosthetic valve size on CT was about 19.5 x 18.9 mm with 290 mm2 of internal area (Figure 1).
  2. Distance from annulus to LM and RCA ostium was 12.5 and 12.1 mm (Figure 2), respectively. The smallest diameter of right and left femoral artery was 7.2 and 7.0 mm (Figure 3).
Procedure
Considering the known size of Biocor epic 21mm valve, we planned to use 23 mm Evolute R valve through right femoral artery. Under general anesthesia care, 6 Fr sheath and temporary pacemaker were inserted through left femoral vein, and 7 Fr sheath and 6 Fr pig-tail catheter were inserted through left femoral artery. After both peripheral angiogram with pig-tail catheter, we checked proper puncture site of right femoral artery. 8 Fr sheath was inserted through right femoral artery and preclosure with Proglide device was done. And then, right femoral artery was dilated and 18 Fr Sentrant sheath was inserted. Aortic root angiography was done ( Movie 1) and an AL 1 diagnostic catheter with a 0.035 inch amplatz stiff wire was used to cross the aortic valve. The 18 Fr CoreValve EVOLUT-R delivery catheter system (AccuTrak) was advanced gently into the vessel. The Core Valve EVOLUT-R crossed over bioprosthetic AV using the super-stiff wire and deployment was done ( Movie 2). Immediately after valve implantation, pressure gradient between left ventricle and aorta was about 10 mmHg. Bioprothetic valve fracture was tried with 20mm True balloon at 12 atm ( Movie 3). Although the fracture phenomenon was not observed, the indentation of the Evolut R was disappeared and pressure gradient between left ventricle and aorta decreased to 0 mmHg. Root angiography showed all coronary arteries was patent and no paravavular regurgitation ( Movie 4). After the intervention, puncture site was sutured by prepared Proglide device.
Reference for Bioprosthetic Valve Fracture
Chhatriwalla AK et al. Circ Cardiovasc Interv. 2017;10:e005216

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