Intracardiac Echo Imaging of a Transfemoral Aortic Edwards SAPIEN Valve Implantation in a Degenerated Bioprosthesis (Valve-in-Valve)
Case description. An 87-year-old male (58 kg body weight, 172 cm height) who had undergone in 1998 an aortic valve replacement (Mosaic®25 mm bioprothesis, Medtronic, Inc., Santa Rosa, California), presented with NYHA Class IV heart failure and a diastolic murmur.
Transesophageal echocardiography (TEE) (Figure 1) showed severe aortic regurgitation due to degenerated bioprosthesis. There were no signs of endocarditis. The patient’s comorbidities included chronic obstructive pulmonary disease, global heart failure (right and left ventricular ejection fraction were respectively 17% and 35%) and severe pulmonary hypertension (> 70 mmHg). Because of these comorbidities and poor hemodynamic conditions (Figure 2), conventional aortic valve replacement was considered too high-risk (logistic EuroSCORE 47%). The patient was therefore advised to undergo transcatheter aortic valve implantation. Since the patient had severe pulmonary hypertension and reduced function of both ventricles precluding chest-opening, we felt that transfemoral aortic valve implantation was the only therapeutic option. After sizing using a 22 mm valvuloplasty balloon, a 23 mm Edwards SAPIEN™ valve (Edwards Lifesciences, Irvine, California) was implanted through the femoral artery under fluoroscopic guidance (Figure 3). The upper edge of the SAPIEN valve was positioned at the level of the small radiopaque rings of the Mosaic bioprosthesis (Figure 4). Immediately after SAPIEN valve deployment, aortic regurgitation disappeared and the transvalvular peak gradient significantly reduced from 38 to 1 mmHg (Figure 5). After deployment, intracardiac echocardiography using a ViewFlex® catheter (St. Jude Medical, St. Paul, Minnesota), showed good positioning and normal function (Figure 6) of the SAPIEN within the Mosaic® prosthesis.
Discussion. Echocardiography is mandatory to assist the procedure of transcatheter aortic valve implantation for baseline (aortic annulus and transvalvular gradient measurement, distribution of calcifications on the leaflets, tricuspid anatomy of the valve) and post-deployment (residual aortic regurgitation, transvalvular gradient, normal motion of the prosthetic leaflets, ascending aorta) assessment. Usually, these evaluations are performed by TEE, which generates two major problems: general anesthesia is required for patient comfort and the TEE probe interferes with the view of the native aortic valve (Figure 7). By using intracardiac echocardiography, patients with contraindications to general anesthesia can undergo transcatheter aortic valve implantation with echocardiographic assistance during the procedure. An intracardiac echocardiography catheter, left in place in the right atrium, allows for accurate visualization of the native valve by fluoroscopy throughout the procedure, which is mandatory for a successful procedure. Problems related to the use of intracardiac echocardiography are the learning curve of the technique, the cost of the catheters and the fact that 3-dimensional images are only acquired with TEE. However, it should be kept in mind that transcatheter aortic valve implantation is an alternative option for fragile patients with several comorbidities and contraindications to surgery and general anesthesia.
This case demonstrates that a team experienced in Edwards SAPIEN valve implantation and ViewFlex® catheter manipulation can use intracardiac echocardiography to accurately assist with transcatheter aortic valve implantation, even in such complex cases as re-do bioprosthesis implantation in a very fragile patient.
Conclusion. ranscatheter aortic valve-in-valve implantation is a challenging procedure for which intracardiac echocardiography may be instrumental in assisting, without requiring general anesthesia or affecting the operator’s ability to visualize the native aortic valve.
From the Cardiovascular Department, Divisions of *Cardiology and §Cardiovascular Surgery, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, 1200 Brussels, Belgium.
The authors disclose no conflicts of interest regarding the content herein.
Manuscript submitted December 9, 2009, provisional acceptance given December 23, 2009, final version accepted February 16, 2010.
Address for correspondence: Joelle Kefer, MD, PhD, Cliniques Universitaires Saint- Luc, Université Catholique de Louvain, Interventional Cardiology, Avenue Hippocrate, 10-2881, 1200 Brussels, Belgium. E-mail: joelle.kefer@uclouvain.be
