Percutaneous Bailout Technique for Trapping an Embolized Valve During Valve-in-Valve TAVR

J INVASIVE CARDIOL 2023;35(3):E160.

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

A 75-year-old man presented with New York Heart Association class III symptoms. History was noteworthy of bicuspid aortic valve (AV) and a ventricular septal defect (VSD), for which he had an AV replacement and VSD closure in 2005. In 2015, he underwent redo AV replacement (23-mm Perimount 2700; Edwards Lifesciences) and root reconstruction.

Echocardiography demonstrated severe bioprosthetic AV stenosis (mean gradient, 50 mm Hg; aortic valve area, 0.84 cm²) and moderate AV regurgitation. Valve-in-valve transcatheter aortic valve replacement with a Sentinel cerebral protection device (Boston Scientific) was recommended. Preoperative computed tomography scan showed dilated aortic root and descending aorta with evidence of pseudocoarctation (Figure 1A).

A 23-mm Edwards Sapien 3 valve (Edwards Lifesciences) was deployed. Before the valve was fully expanded, it embolized into the aortic root due to stored tension (Video 1). Attempts to insert the valve inside the prosthetic valve were unsuccessful. An additional 23-mm S3 valve was advanced through the embolized valve and was successfully deployed (Figure 1B). In order to stabilize the first S3 valve, an uncovered 36- x 120-mm dissection stent was implanted via an extra-stiff Lunderquist wire (Cook Medical). A TriLobe balloon (Gore) was advanced over the wire and inflated within the embolized valve to ensure appropriate stent apposition (Figure 1C). A final angiogram showed good flow into the aorta and good stent apposition (Figure 1D).

This case highlights the need for multidisciplinary team approach and the in-depth knowledge of various devices and techniques available.

Affiliations and Disclosures

From the ¹Division of Cardiovascular Medicine, ²Department of Cardiothoracic Surgery, and ³Division of Vascular Surgery, Stanford University School of Medicine, Stanford, California.

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.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted September 15, 2022.

Address for correspondence: Konstantinos E. Stathogiannis, MD, PhD, Heart and Vascular Center, 300 Pasteur Drive, Stanford, CA 94305. Email: kstathog@hotmail.com