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a Division of Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
b Division of Cardiology, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
Accepted for publication February 16, 2009.
* Address correspondence to Dr Ye, Division of Cardiac Surgery, St. Paul's Hospital, 1081 Burrard St, Vancouver, British Columbia, 6Z 1Y6, Canada (Email: jye{at}providencehealth.bc.ca).
| Drs Webb and Cheung disclose a financial relationship with Edwards Lifesciences.
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Abstract |
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Aortic valve replacement (AVR) remains the gold standard therapy for severe aortic disease and failed prosthetic valves. With the increasing safety of cardiopulmonary bypass and cardiac surgical techniques, AVR carries a low risk of operative mortality and morbidity. However, the risk of operative mortality and morbidity increases in elderly patients who undergo reoperative AVR. Moreover significant numbers of elderly patients with degenerated bioprostheses may be declined or may not be referred for reoperative AVR due to unacceptable operative mortality and morbidity. Recently minimally invasive transcatheter aortic valve implantation (AVI) has been demonstrated as feasible in patients with severe native aortic stenosis who would be at high risk with conventional AVR [1–4]. We now report a 16-month outcome of our first transcatheter valve-in-valve AVI of a balloon-expandable bioprosthesis into failed surgically implanted bioprostheses. This case has never been included in any of our previous reports or publications.
The procedures were approved by the Therapeutic Products Directorate, Department of Health and Welfare, Ottawa, Canada, for compassionate clinical use in patients deemed not to be candidates for open-heart surgery.
An 85-year-old frail male had undergone conventional AVR with a 25-mm Edwards porcine valve (Edwards Lifesciences, Irvine, CA) and coronary artery bypass 8 years previously. He developed severe aortic regurgitation, associated with pulmonary hypertension (systolic pressure 60 mm Hg) and preserved left ventricular systolic function. All five coronary artery bypass grafts were patent. He was in the New York Heart Association (NYHA) functional class III–VI with dyspnea and was hospitalized due to congestive heart failure. Reoperative AVR was declined because of age, frailty, and multiple patent grafts. His logistic EuroSCORE was 31%.
Percutaneous transfemoral valve-in-valve AVI was initially attempted. After balloon valvuloplasty, a 23-mm Edwards-SAPIEN valve (Edwards Lifesciences) was positioned within the previous surgically implanted 25-mm Edwards conventional bioprosthesis, such that the radiopaque base of the surgical prosthesis and the transcatheter prosthesis were at the same level. As the balloon was expanded the struts of the surgical bioprosthesis splayed because the positioning of the SAPIEN bioprosthesis was slightly too aortic. This, in combination with noncoaxial alignment, resulted in the transcatheter bioprosthesis being displaced and immediately embolized into the ascending aorta (Fig 1A). The transcatheter valve was captured with the balloon catheter and it was manipulated into the distal aortic arch where it was overdilated and permanently secured (Fig 1B). More severe aortic regurgitation was noted, but the patient remained stable and intubated.
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Comment |
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From this case experience, we found that accurate positioning is more challenging for valve-in-valve AVI than for valve implantation into a calcified native aortic valve. Unlike severe native aortic stenosis that has a significant amount of calcification, a failed surgical bioprosthetic valve usually has little calcification and has a very limited landing zone for anchoring a transcatheter stent bioprosthesis. The metal frame of a surgical bioprosthesis, which is visible on fluoroscopy, can be used for the guidance of positioning during valve-in-valve implantation. The inflow edge of the frame of a surgical bioprosthesis on fluoroscopy does not perfectly match the real inflow edge of the bioposthesis because of sewing material. Therefore, the inflow edge of a transcatheter stent bioprosthesis should be positioned slightly below the inflow edge of the metal frame of a surgical bioprosthesis to achieve good stability. From this case experience, at least for this combination of surgical and transcatheter valves, it appears that an ideal position would be the alignment of the bottom of a transcatheter valve stent slightly below (aimed during the transapical approach), rather than at the same level (aimed during the initial transfemoral approach) of the bottom of the metal frame of the surgical tissue valve. Similarly, a good coaxial alignment of an implanted transcatheter valve with a surgically implanted conventional bioprosthetic valve is necessary because of a narrow landing zone of conventional bioprostheses for anchoring a transcatheter valve. Compared with the retrograde transfemoral approach, the transapical approach has a much shorter and straighter route from the left ventricular apex to the aortic valve, which allows better coaxial alignment.
A paravalvular leak may be less likely due to more favorable sealing by the circular bioprosthetic valve frame or stent, and good visibility of the valve plane at the time of positioning. In this case, postoperative aortic regurgitation was not observed during the 16-month follow-up.
In conclusion, off-pump transcatheter, transapical valve-in-valve aortic valve implantation could be an alternative for failed bioprostheses in selected high-risk patients. However, further clinical assessment is required before this method can be broadly applied.
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