Percutaneous transcatheter aortic valve-in-valve replacement for degenerated sutureless aortic valve

Background:  Sutureless aortic valves are an alternative to conventional surgical aortic valve replacement with proposed benefits including shortened cardiopulmonary bypass and aortic crossclamp times.  These devices differ... [ view full abstract ]

Background:  Sutureless aortic valves are an alternative to conventional surgical aortic valve replacement with proposed benefits including shortened cardiopulmonary bypass and aortic crossclamp times.  These devices differ structurally from standard valves and little data is available addressing the benefits and safety of transcatheter valve-in-valve implantation for degenerated sutureless valves.

Case Description:  An 80 year old female with a history of sutureless (Perceval) aortic valve replacement for severe aortic stenosis and one-vessel coronary artery bypass grafting presented with worsening exertional dyspnea and angina.  Transesophageal echocardiography reports from outside hospital noted development of moderate to severe valvular and perivalvular aortic insufficiency and valvular thrombus.  Given the patient’s multiple comorbidities, she was considered to be high surgical risk and the decision was made to proceed with valve-in-valve transcatheter aortic valve replacement.  Pre-operatively the patient was hypotensive and anemic with resting angina.  Arterial and central venous access was challenging given peripheral arterial disease, presence of a left arm hemodialysis fistula and occlusive thrombus in the right internal jugular vein.  The patient underwent an uneventful anesthetic induction and intubation.  Intraoperative transesophageal echocardiography revealed restricted prosthetic aortic valve leaflet motion, severe valvular and moderate perivalvular leak and moderate mitral regurgitation.  Coronary catheterization revealed an occluded graft to the left circumflex artery and drug eluting stent was placed.  Percutaneous transcatheter valve in valve implantation was performed with a 23-mm Edwards Sapien S3 with good valve seating and only trivial perivalvular leak.  Post-deployment the patient developed complete heart block.  Attempts to place a permanent pacemaker were unsuccessful due to complete right central venous occlusion and an inaccessible left side due to fistula, so left femoral Permatemp was placed.  The patient was extubated and transferred to the intensive care unit awaiting leadless pacemaker placement.  On two-month follow up the patient continues to report significant symptomatic and functional improvement.

Discussion:  Early results from a multicenter study on outcomes for patients receiving the Perceval valve report low rates of major perivalvular leak, valve degeneration and reintervention.  The structural characteristics of these devices present special considerations for valve-in-valve implantation with concern regarding valve stability and fixation.  A recent pilot series reported successful use of transcatheter aortic valve replacement for degenerated sutureless aortic valves with no early major adverse events.  Larger, multicenter studies are needed to evaluate outcomes.