Remedy of a Deep Downward Shift of a Valve Using Double Snares and “Sandwich” Technique

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A 76-year-old man diagnosed with severe pure native aortic regurgitation (PNAR) underwent transcatheter aortic valve replacement (TAVR) due to high surgical risk. The computed tomography angiography showed no calcification and no stenosis of the aortic valve, with an annulus perimeter of 81.1 mm (Figure 1A) and sinus diameters of 35 to 38 mm (Figure 1B).

A 30-mm self-expanding VitaFlow valve (MicroPort) was transfemorally delivered and released 1 mm below the annulus plane, but moved downward to the deep left ventricle, affecting the mitral valve function (Figure 2A, Video 1). A snare (Shanghai Shape Memory Alloy Co.) through the transfemoral artery was used to drag the valve upward but failed (Figure 2B) because the unilateral pulling could cause misalignment between the valve and aorta, resulting in increased frictional force when the valve moves upward. A second snare (Shanghai Shape Memory Alloy Co.) was then applied alongside the first snare through the right radial artery to keep the valve and aorta coaxial, and the valve was finally pulled up to the ascending aorta (Figure 2C and D, Video 2).  

Subsequently, we inserted a 0.035-inch Amplatz Super Stiff wire (Boston Scientific) into the transfemoral accessory 6-French pigtail catheter (Cordis) to enhance the support force and pushed the valve into the bottom of the sinus of Valsalva (Figure 3A and B). Next, another 30-mm self-expanding VitaFlow valve was valve-in-valve released 3 mm below the native annulus (Figure 3C, Video 3). Finally, the first prosthesis, the autologous valve, and the second prosthesis formed a “sandwich” structure, in which the first prosthesis was placed in the bottom of the sinus of Valsalva, preventing the downward movement of the 2 prostheses (Figure 3D). The patient was discharged 4 days after the procedure with good function and no shift of the valves, which was confirmed by echocardiography.

This is the first report to demonstrate a successful remedy for a deep downward shift of a self-expanding valve using the double snares technique, as well as the rescue of an up-downward shift of the valve using the transcatheter “sandwich” valve-in-valve implantation technique in a patient with PNAR. Valve displacement frequently occurs when performing TAVR for PNAR using a self-expanding valve, resulting in higher rates of transferring to surgery, valve-in-valve implantation, and pacemaker implantation. Our case provides a new technique for treating an upward and downward valve shift.

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