Transfemoral Valve-in-Valve Transcatheter Aortic Valve Implantation (TAVI) in a Patient With Previous Endovascular Aortic Repair (EVAR)

Abstract: A 90-year-old man presented with increasing exertional breathlessness. He had previous implantation of a Perimount bioprosthetic aortic valve (Edwards Lifesciences) and coronary artery bypass graft surgery. Due to severe transvalvular bioprosthetic regurgitation with preserved left ventricular dimensions and ejection fraction, the heart team decided on valve-in-valve transcatheter aortic valve implantation via the transfemoral route in view of the patient’s prohibitively high surgical and anesthetic risk. The patient had an uncomplicated recovery and was symptomatically much improved at 3-month follow-up.

J INVASIVE CARDIOL 2016;28(7):E69-E70

Key words: transcatheter aortic valve implantation, valve-in-valve

Case Presentation

A 90-year-old man presented with increasing exertional breathlessness (New York Heart Association [NYHA] class III). He had previously been treated with bioprosthetic aortic valve replacement with a 25 mm Perimount device (Edwards Lifesciences) and coronary artery bypass graft surgery. His past medical history included endovascular aortic repair (EVAR) with a bifurcated device (Figures 1A and 1B) 4 years previously, chronic kidney disease, bilateral carotid stenoses, and myelodysplasia. A resting transthoracic echocardiogram demonstrated severe transvalvular bioprosthetic regurgitation (Figure 1C) with preserved left ventricular dimensions and ejection fraction. His logistic EuroScore was 54%. The heart team decided he would be best treated with valve-in-valve transcatheter aortic valve implantation via the transfemoral route in view of his prohibitively high surgical and anesthetic risk. 

Under conscious sedation with local anesthesia, a 14 Fr sheath was carefully placed via the right femoral artery and advanced through the preexisting EVAR. A 26 mm Sapien 3 prosthesis (Edwards Lifesciences) was then carefully maneuvered through the in situ EVAR (Figure 1D) to avoid stent movement, and was successfully deployed without complication (Figure 1E). Postprocedural transthoracic echocardiogram demonstrated no residual aortic regurgitation (Figure 1F). The patient had an uncomplicated recovery and was discharged on day 3. At 3-month follow-up, he was symptomatically much improved (NYHA class II). 

Discussion

Transcatheter valve-in-valve treatment for degenerated bioprosthetic valves is now an established treatment option for patients, with good safety and efficacy.¹ The transfemoral vascular access route is the default access route due to shorter procedure times, faster recovery, and improved outcomes.² The current generation of lower-profile devices, which have improved maneuverability, provide the ability to negotiate aortic pathology including the presence of preexisting stents. With careful preprocedural planning coupled with improvements in technology and operator experience, the presence of an EVAR and challenging anatomy should not preclude the use of the transfemoral route.

References

1.    Dvir D, Webb J, Brecker S, et al. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry. Circulation. 2012;126:2335-2344.

2.    Moat NE, Ludman P, de Belder MA, et al. Long-term outcomes after transcatheter aortic valve implantation in high-risk patients with severe aortic stenosis: the U.K. TAVI (United Kingdom Transcatheter Aortic Valve Implantation) registry. J Am Coll Cardiol. 2011;58:2130-2138.

From the Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, United Kingdom.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted March 14, 2016, and accepted March 24, 2016.

Address for correspondence: Neil Ruparelia, DPhil, MRCP, Department of Cardiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS, United Kingdom. Email: neil.ruparelia@gmail.com