Valve-in-Valve Implantation to Seal Post-Dilation-Induced Annular Rupture in Transcatheter Aortic Valve Replacement

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Aortic annular rupture is a serious complication of transcatheter aortic valve replacement (TAVR). Emergency cardiac surgery repair is the traditional treatment of choice; however, it is associated with high mortality. Here, we report a case of annulus rupture post-balloon dilation during TAVR, which was sealed successfully with the valve-in-valve implantation technique.

An 85-year-old woman was admitted to our hospital with severe symptomatic aortic stenosis. Preoperative computed tomography and transesophageal echocardiography (TEE) revealed a type I bicuspid aortic valve (aortic annulus diameter: 26 mm; Figure 1, Videos 1 and 2). After pre-dilation with an 18-mm balloon (Figure 2A, Video 3), a 26-mm self-expandable Taurus valve (PEIJIA Medical) was deployed (Figure 2B, Video 4). After valve expansion, post-dilation was performed using the 18-mm balloon (Figure 2C, Video 5). Aortography post-dilation indicated middle paravalvular leakage (Figure 2D, Videos 6 and 7), and the patient’s hemodynamics became unstable. TEE revealed cardiac tamponade and tissue swelling around the left sinus, with extensive calcification bulging out during post-dilation (Figure 3, Videos 8 and 9). Despite pericardial fluid drainage, autologous blood transfusion, and antagonizing anticoagulation (Figure 2E), the pericardial fluid increased in volume. After a second 26-mm valve was implanted within the first prosthesis (Figure 2F, Video 10), the patient’s hemodynamics stabilized. TEE revealed no increase in pericardial effusion and a decrease in the paravalvular leak (Video 11). Thus, valve-in-valve implantation may be an effective treatment to seal post-dilation-induced annular rupture during TAVR.

Affiliations and Disclosures

From the ¹Zhuhai People's Hospital, Zhuhai hospital affiliated with Jinan University, Zhuhai, Guangdong, China; ²Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; ³National Clinical Research Center for Interventional Medicine, Shanghai, China.

Drs Wang and Qi contributed equally to the manuscript.

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

Funding: The present study was supported by the Medical Science and Technology Research Fund of Guangdong Province (grant no.: A2021089).

Consent statement: The authors confirm that informed consent was obtained from the patient for the procedure(s) described herein.

Address for correspondence: Wenzhi Pan, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China. Email: peden@sina.com

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