Valve-in-valve concept in acute aortic insufficiency following transcatheter aortic valve replacement

Introduction: Transcatheter heart valve replacement has become an alternative treatment for aortic valve stenosis. Malfunction of this biological heart valve prosthesis formerly led to open chest surgery and valve replacement with aortotomy and extracorporal circulation. Our catheter-based valve-in-valve concept avoids an invasive reoperation.

Aims: We report the case of an 82-years-old patient (EuroSCORE 67%) with low cardiac output syndrome from severe aortic regurgitation after catheter-based implantation (femoral approach) of a Medtronic CoreValve prosthesis (29 mm in diameter). Echocardiography revealed a huge paravalvular leakage due to an undersizing of the implanted prosthesis. Because of the bad condition of the patient the heart team decided for a catheter-based transapical reintervention. The chest was entered through an anterolateral minithoracotomy. After access over the apex a 29-mm Edwards SAPIEN pericardial valve was advanced into the 29 mm Medtonic CoreValve prosthesis in position of the aortic annulus and expanded under rapid pacing.

After valve-in-valve reintervention and overexpansion of the Medtronic CoreValve prosthesis, intraoperative transesophageal echocardiography and fluoroscopy confirmed absence of aortic regurgitation. Intraaortic counterpulsation was held for 3 days. The patient was discharged 14 days later and is doing well.

Discussion: This case demonstrates feasibility of the transcatheter valve-in-valve concept for the treatment of huge paravalvular leakage after interventional implantation of a Medtronic CoreValve prosthesis.