Successful Valve-in-Valve Replacement Using Intravascular Lithotripsy for Femoral Access in an Elderly Patient With Critical Aortic Stenosis and Extensive Vascular Calcification

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An 87-year-old man with a history of heart failure and a modified bio-Bentall Mitroflow 23-mm bioprosthesis (Sorin) was referred to our institution for critical aortic stenosis, which was confirmed by transesophageal echocardiography. Pre-procedural computed tomography revealed slightly calcified bioprosthesis leaflets, adequate coronary ostia height, and a slightly angled Bentall tube graft measuring 29 mm in diameter at the aortic anastomosis (Figure A).

Considering the high surgical risk (EuroScore II 17.8%), a valve-in-valve procedure was deemed necessary. The femoral access was compromised by extensive calcification and an infrarenal aneurysm with a thrombus extending into both femoral arteries (Figure B and C). To address this, intravascular lithotripsy was performed using a Shockwave medical device, which delivered 5 cycles of 30 pulses via a 7- x 60-mm balloon to the right common femoral artery (Figure D, Video 1). A 20- x 40-mm Atlas Gold balloon (BD) was then advanced through the right femoral artery sheath to crack the Mitroflow aortic bioprosthesis (Figure E). Subsequently, a 23-mm ALLEGRA transcatheter valve (Biosensors) was implanted into the degenerated bioprosthesis, resulting in a mean valve gradient reduction to 3 mm Hg with no significant insufficiency (Figure F, Video 2). No intraoperative complications occurred. The delivery system was removed, and femoral access was closed using a MANTA 18-French vascular closure device (Teleflex) (Video 3). The patient was discharged without complications.

This image underscores the pivotal role of advanced imaging in facilitating valve-in-valve interventions for high-risk patients with restricted access, showcasing the precise procedural execution and highlighting minimal postoperative recovery.

Affiliations and Disclosures

Borja Rivero-Santana, MD^1,2; Guillermo Galeote, MD, PhD¹; Alfonso Jurado-Roman, MD, PhD^1,2; Santiago Jiménez-Valero, MD, PhD^1,2; Ariana Gonzálvez-García, MD¹; Raul Moreno, MD, PhD^1,2

From the ¹Cardiology Department, La Paz University Hospital, Madrid, Spain; ²La Paz University Hospital, IdiPAZ Research Institute, Madrid, Spain.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the procedures described in this manuscript.

Address for correspondence: Borja Rivero-Santana, MD, La Paz University Hospital. Paseo de la Castellana 261, 28046. Madrid, Spain.  Email: Borja.riversa@gmail.com; X: @Borja.Riversa