Ann Thorac Surg 2011;92:1102-1104. doi:10.1016/j.athoracsur.2011.03.052
© 2011 The Society of Thoracic Surgeons
Case Reports
Management of Aortic Valve Dysfunction After Transapical Approach Using the Technique "Valve After Valve"
Nuria Miranda-Balbuena, MD*,
Omar A. Araji, MD, PhD,
Maria Ángeles Gutierrez-Martín, MD,
Emiliano A. Rodriguez-Caulo, MD,
Jose Miguel Barquero, MD,
Antonio Fernandez, MD
Cardiovascular Surgery Department, Virgen Macarena University Hospital, Sevilla, Spain
Accepted for publication March 8, 2011.
* Address correspondence to Dr Miranda-Balbuena, Cardiovascular Surgery Department, Virgen Macarena University Hospital, Avenida Dr Fedriani 3, Sevilla, 41009 Spain (Email: demirandab{at}yahoo.es).
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Abstract
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We report a case of a 77-year-old patient with severe aortic stenosis who underwent transapical aortic valve implantation with a 23-mm Edwards Sapien valve (Edwards Lifesciences Inc, Irvine CA). This procedure was complicated with the occurrence of an acute regurgitation due to entrapment of one of the leaflets that was successfully managed by valve after valve technique.
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Introduction
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The transapical aortic valve implantation is an innovative technology for symptomatic patients with severe aortic valve stenosis with high risk for surgery [1]. Among the intraoperative complications that can occur is an acute structural, prosthetic valve dysfunction causing acute severe aortic regurgitation with hemodynamic deterioration of the patient, which requires a direct valve after valve implantation.
We report the case of a 77-year-old woman with repeated clinical angina and New York Heart Association functional class III. She had a background history of treated hypertension, dyslipidemia, minor degree Alzheimer's disease, chronic C hepatitis, biliary lithiasis, and moderate mitral regurgitation. She was declined for traditional aortic valve surgery based on her age and comorbidities, with high surgical risk for conventional surgery. Her predicted perioperative mortality based on The Society of Thoracic Surgeons' score was 17.2%. On echocardiogram, aortic gradients of 63 mm HG (peak) and 43 mm HG (mean) were noted with a valve area of 0.6 cm2 and an annulus measurement of 20 mm. A 23-mm Edwards Sapien valve (Edwards Lifesciences, Irvine, CA) was planned.
The patient underwent a transapical aortic valve implantation procedure, a 6-French pigtail was positioned in the ascending aorta through a femoral approach and a temporary pacemaker was placed in the right ventricle. After the localization of the apex by echocardiography, we performed a left mini-thoracotomy, and two apical pursestring sutures were placed. Then we punctured the apex with a needle and passed the 0.035 soft hydrophilic wire (Terumo Inc, Tokyo, Japan) and a JR4 diagnostic catheter was tracked in the ascending aorta, crossing the arch down to the abdominal aorta. At this point, the soft hydrophilic wire was changed for an Amplatz super stiff guidewire. Aortic valvuloplasty was performed during right ventricular pacing (200 bpm) using a Nucleus 25/40-mm balloon (NuMed, Inc, Hopkinton, NY); the 23-mm Edwards Sapien aortic prosthesis (Edwards Lifesciences) was positioned across the native valve and was deployed under fluoroscopic guidance. At the end of the procedure, the echocardiogram showed a lack of mobility of one of the leaflets (Figs 1A,
1B). Rapid hemodynamic collapse occurred, requiring increased ionotropic support and 4 minutes of cardiopulmonary resuscitation to maintain adequate mean arterial pressures. Attempts to free the valve leaflets with a pigtail catheter were unsuccessful. A second 23-mm Edwards Sapien valve was immediately crimped and positioned across the first valve, which resolved the regurgitation (Figs 1C, 1D).
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Fig 1. Transesophageal echocardiogram in short-axis and long-axis view demonstrates the aortic valve function at different stages of the procedure. (A) Long-axis view shows the acute central regurgitation. (B) Short-axis view shows in diastole the two functioning leaflets and the entrapped one. (C) Short-axis view of the functioning three leaflets of the inner valve after valve after valve technique. (D) Long-axis view shows no regurgitation.
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The patient had a very stormy postoperative period, but she was discharged in good condition after 2 months of total hospital stay.
The patient was asymptomatic at 4 months after her hospital discharge, with the valve properly positioned, and no dislodgment or migration of the inner valve was observed (Fig 2), and the transthoracic echocardiographic control showed a normally functioning prosthesis, with a mean gradient of 8 mm Hg and absence of aortic regurgitation.
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Comment
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Complications of the transapical aortic valve implantation can be divided into acute structural valve failure, nonstructural valve failure, and other procedure-related issues. Strategies to avoid, diagnose, and manage nonstructural valve failure, which include paravalvular aortic regurgitation, malposition, including valve migration, and procedure-related complications that include acute coronary artery occlusion, cardiac tamponade, aortic annular tear, vascular injury (including access site injury), acute heart block, and stroke are well-described [2–7]. However, acute structural valve failure is a rare, but potentially catastrophic complication that is not well-described and may be generated by several factors: (1) At the time of implantation of the Edwards Sapien valve, an adequate pressure gradient between the left ventricle and the aorta (10 mm Hg ± 5 mm Hg) is required for closure of the valve. When the valve is crimped on the balloon catheter, memory will be created in the leaflets in an open position. To ensure the closure of the leaflets, suitable pressure gradient must exist across the valve during diastole. The absence of this gradient can lead to acute valvular dysfunction, (2) the perforation or tearing of a valve leaflet during valve preparation or deployment, (3) the protrusion of a portion of the native valve leaflet within or above the stent that may cause entrapment of the bioprosthetic valve leaflet, (4) the deformation of the stent by a calcified and distorted annulus that can lock the leaflet in the open position, and (5) a low bioprosthesis positioning that cause the tip of one of the native valve leaflets to bend over the top of the stent during diastole. Therefore, this would prevent the diastolic flow closing the bioprosthetic valve leaflet located underneath this "roof" formed by the tip of the native leaflet. In our case, the valve was well-positioned with two functioning leaflets, and just one leaflet that did not close in diastole. So we postulate that this rare case may be due to the entrapment of the leaflet in the housing stent during implantation, as it could be seen in Figure 1B. Prior to implanting the new valve, we tried to move the responsible leaflet of regurgitation using the pigtail catheter to achieve the proper working valve, but this maneuver was ineffective.
We believe that this case of structural valve failure with one immobile leaflet is rarely described in the literature. It is important to recognize this in a timely fashion to enable prompt treatment. This complication was overcome using immediate valve-in-valve technique to deploy a second valve within the first valve, immediately giving successful outcome and excellent result.
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References
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- Dewey TM, Brown DL, Herbert MA, et al. Effect of concomitant coronary artery disease on procedural and late outcomes of transcatheter aortic valve implantation Ann Thorac Surg 2010;89:758-767.[Abstract/Free Full Text]
- Pasupati S, Puri A, Devlin G, Fisher R. Transcatheter aortic valve implantation complicated by acute structural valve failure requiring immediate valve in valve implantation Heart, Lung and Circulation 2010;19:611-614.
- Stabile E, Sorropago G, Cota L, et al. Percutaneous aortic valve management of malpositioned with a transapical "valve-in-valve." Ann Thorac Surg 2010;89:e19-e21.[Abstract/Free Full Text]
- Ducrocq G, Francis F, Serfaty JM, et al. Vascular complications of transfemoral aortic valve implantation with the Edwards SAPIEN prosthesis: incidence and impact on outcome EuroIntervention 2010;5:666-672.[Medline]
- Sinhal A, Altwegg L, Pasupati S, et al. Atrioventricular block after transcatheter balloon expandable aortic valve implantation JACC Cardiovasc Interv 2008;1:305-309.[Medline]
- Hanzel GS, O'Neill WW. Complications of percutaneous aortic valve replacement: Experience with the Cribier-Edwards percutaneous heart valve EuroIntervention 2006;1(Suppl 1):A3-A8.
- Al Ali AM, Altwegg AL, Webb JG, et al. Prevention and management of transcatheter balloon expandable aortic valve malposition Catheter Cardiovasc Interv 2008;72:573-578.[Medline]
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Abstract
Introduction
