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Ann Thorac Surg 2008;85:1072-1073. doi:10.1016/j.athoracsur.2007.12.040
© 2008 The Society of Thoracic Surgeons
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Case Reports

Human Minimally Invasive Off-Pump Valve-in-a-Valve Implantation

Thomas Walther, MD, PhDa,*, Jörg Kempfert, MDa, Michael A. Borger, MD, PhDa, Jens Fassl, MDb, Volkmar Falk, MD, PhDa, Johannes Blumenstein, MSa, Mark Dehdashtian, PhDd, Gerhard Schuler, MD, PhDc, Friedrich W. Mohr, MD, PhDa

a Department of Cardiac Surgery, Universität Leipzig, Herzzentrum, Leipzig, Germany
b Department of Anaesthesia, Universität Leipzig, Herzzentrum, Leipzig, Germany
c Department of Cardiology, Universität Leipzig, Herzzentrum, Leipzig, Germany
d Edwards Laboratories, Irvine, California

Accepted for publication December 13, 2007.

* Address correspondence to Dr Walther, Universität Leipzig, Herzzentrum, Klinik für Herzchirurgie, Strümpellstr. 39, 04289, Leipzig, Germany (Email: walt{at}medizin.uni-leipzig.de).


Dr Dehdashtian discloses that he has a financial relationship with Edwards Lifesciences.

 

   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Reoperative heart valve replacement for degenerated xenografts is associated with an increased surgical risk. We used our experience with transcatheter transapical aortic valve implantation to perform a transapical off-pump aortic valve-in-a-valve implantation. Hemodynamic function was excellent and the patient had a fast and uneventful recovery.

Heart valve replacement is a routinely performed in elderly patients using third-generation xenografts, with modern anticalcification treatment providing good hemodynamic function and sufficient longevity [1]. However, xenograft degeneration with subsequent repeat stenosis or incompetence requiring reoperation may occur. Reoperation is technically feasible in most patients, but the risk may be increased. Relatively few studies are published on such patients, but most quote a mortality risk for valve reoperation between 6% and 15% [2, 3]. Transcatheter heart valve implantation has been recently introduced into clinical practice using transfemoral and transapical approaches [4–6]. On the basis of this experience together with experimental testing demonstrating excellent results for valve-in-a-valve (VinV) implantation [7] we were able to successfully perform VinV implantation.

In March 2007, an 82-year-old woman presented with symptomatic (New York Heart Association Functional Class III) aortic xenograft stenosis 9 years after receiving a 21-mm Perimount prosthesis (Edwards Lifesciences, Irvine, CA). Echocardiography revealed severe aortic stenosis with a maximum flow velocity of 4.5 m/s, a valve opening area of 0.8 cm2, and severely restricted cusp motion. Because of her significantly increased perioperative risk, with a logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) predicted risk for death of 21%, and the Society Thoracic Surgeons risk assessment of 9.2%, she was considered for transapical minimally invasive off-pump VinV implantation. The patient gave informed consent for a protocol that has been approved by our local Ethics Board. Valve size selection for VinV implantation was based on specific bench testing.

The VinV implantation was performed in a hybrid operative theatre. Femoral arterial and venous wires were inserted percutaneously, and an arterial sheath was placed. This would allow for immediate femoral cannulation and initiation of cardiopulmonary bypass, if required. A pigtail catheter was introduced through the arterial sheath into the aortic root for angiographic visualization. After an anterolateral minithoracotomy in the fifth intercostal space and vertical pericardiotomy, two purse-string sutures were placed in the apex of the left ventricle.

The Seldinger technique was used to insert a 14F sheath antegrade across the stenosed xenograft. A superstiff guidewire was then introduced across the aortic arch into the descending aorta. Balloon dilatation of the stenosed xenograft was performed during a brief episode of rapid ventricular pacing (RVP) at 150 beats/min.

A 33F transapical sheath and a cuffed Cribier Edwards transcatheter valve (Edwards Lifesciences) were subsequently inserted. The valve was positioned with the lower edge approximately 2 mm below the circular metal band of the stenosed xenograft (Fig 1). The VinV implantation was performed by inflating the balloon during a second episode of RVP (Fig 2). Good VinV position with full stent expansion and a slightly concave stent configuration at the inflow and outflow aspect was obtained (Fig 3). The guidewire and sheath were retrieved, and the left ventricular apex and the minithoracotomy were closed.


Figure 1
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  		Fig 1. Valve-in-a-valve positioning.

 

Figure 2
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  		Fig 2. Valve-in-a-valve dilatation.

 

Figure 3
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  		Fig 3. Final result shows a 23-mmn Edwards SAPIEN Transcatheter Heart Valve (THV) within a 21-mm Edwards Perimount conventional xenograft (Edwards Lifesciences, Irvine, CA). Aortic root angiogram confirms excellent valve-in-a-valve position, without incompetence, and patent coronary arteries.

 
Hemodynamic function was stable throughout the procedure. Excellent valve function was confirmed by echocardiography and angiography, with no incompetence and low gradients (maximum velocity, 2.1 m/s). The patient had an uneventful recovery and was discharged in good health on postoperative day 11. The patient is doing well at home without any symptoms and with good valve function at 3 months of follow-up.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
Reoperative heart valve replacement may be associated with an increased surgical risk [2, 3]. Recently, transcatheter minimally invasive aortic valve implantation, using the transfemoral or the transapical approach, has been successfully performed in high-risk patients with native aortic valve stenosis [4–6]. The VinV implantation is a logical further step. Experimental VinV testing [7], laboratory analysis on the ideal valve size to be implanted into the degenerated xenograft and clinical experience with transapical aortic valve implantation in patients with native aortic valve disease were important prerequisites for successful clinical application of the VinV concept. Valve-in-a-valve implantation is an intriguing concept for minimally invasive reoperative heart valve replacement in the presence of degenerated xenografts, especially in high-risk elderly patients.

The minimally invasive approach and the good hemodynamic outcome led to a fast and uneventful recovery in our patient. It is possible that such minimally invasive VinV re-replacement procedures may lead to more frequent use of xenografts during initial heart valve procedures or a lowering of the recommended age for bioprosthetic implantation in the future.

Future consideration of VinV procedures in patients with failing bioprosthetic valves should take into account the different failure modes of porcine vs pericardial xenografts. Whereas bovine pericardium tends to have progressive stiffening that leads to stenosis, porcine cusps tend to develop severe calcification that may potentially lead to a higher risk of embolization during VinV implantation. We believe that minimally invasive beating heart off-pump VinV implantation offers a valuable therapeutic option for future patients, especially for those at high surgical risk.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Schoen FJ, Levy RJ. Calcification of tissue heart valve substitutes: progress toward understanding and prevention Ann Thorac Surg 2005;79:1072-1080.[Abstract/Free Full Text]
  2. Jamieson WRE, Burr LH, Miyagishima RT, et al. Reoperation for bioprosthetic aortic structural failure - risk assessment Eur J Cardiothorac Surg 2003;24:873.[Abstract/Free Full Text]
  3. Eitz T, Fritzsche D, Kleikamp G, Zittermann A, Horstkotte D, Körfer R. Reoperation of the aortic valve in octogenarians Ann Thorac Surg 2006;82:1385-1391.[Abstract/Free Full Text]
  4. Grube E, Schuler G, Buellesfeld L, et al. Percutaneous aortic valve replacement for severe aortic stenosis in high risk patients using the second- and current third-generation self-expanding CoreValve prosthesis: device success and 30-day clinical outcome J Am Coll Cardiol 2007;50:69-76.[Abstract/Free Full Text]
  5. Webb JG, Chandavimol M, Thompson CR, et al. Percutanous aortic valve implantation retrograde from the femoral artery Circulation 2006;113:842-850.[Abstract/Free Full Text]
  6. Walther T, Falk V, Borger MA, et al. Minimally invasive transapical beating heart aortic valve implantation—proof of concept Eur J Cardiothorac Surg 2007;31:9-15.[Abstract/Free Full Text]
  7. Walther T, Falk V, Dewey T, et al. Valve-in-a-valve concept for transcatheter minimally invasive redo xenograft implantation J Am Coll Cardiol 2007;50:56-60.[Abstract/Free Full Text]



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This Article
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Michael A. Borger
Volkmar Falk
Gerhard Schuler
Friedrich W. Mohr
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Right arrow Valve disease

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