Abstract
Transcatheter aortic valve replacement in extra-large annulus is challenging because of the limited sizes and data of the current commercial prosthesis sizes available. We present a case of successful transcatheter aortic valve replacement with a new balloon-expandable SAPIEN 3 Ultra RESILIA valve for an aortic annulus area >1,000 mm2 on computed tomography.
Key Words: balloon-expandable valve, overfilling, transcatheter aortic valve replacement
Graphical abstract
An 85-year-old man with cardiac sarcoidosis presented to our institution with progressive dyspnea. Transthoracic echocardiography (TTE) showed decreased left ventricular ejection fraction of 45.1% with a significantly enlarged left ventricular cavity and mixed severe aortic stenosis with aortic valve area of 0.89 cm2 and moderate aortic regurgitation with effective regurgitant orifice area of 0.23 cm2. A moderately calcified tricuspid aortic valve with an annular area of 1,021.3 mm2 was detected with computed tomography (CT). The largest 29-mm SAPIEN 3 Ultra RESILIA transcatheter heart valve (THV) (Edwards Lifesciences) was 37.3% undersized for his annulus area. However, considering his high surgical risk with a Society of Thoracic Surgeons score of 10.0%, our heart team decided to perform transcatheter aortic valve replacement (TAVR) after fully explaining to the patient the possibility of fatal complications such as valve embolization and significant aortic regurgitation (Figures 1A and 1B, Video 1).
Figure 1.
Successful Balloon-Expandable Valve Implantation for Extra-Large Annulus
(A and B) Preprocedural contrast-enhanced computed tomography showing a tricuspid calcified aortic valve with an annular area of 1,021.3 mm2 and perimeter of 114.7 mm. (C) Postdilation was performed with the extra 7 mL of volume after the 29-mm balloon-expandable valve implantation. (D) Postprocedural transesophageal echocardiography showing mild paravalvular leakage. (E) Simultaneous assessment of left ventricular (LV) and aortic (AO) pressure after the valve implantation. (F) Postprocedural CT showing the stent area of the valve was 797.3 mm2 without leaflet thrombosis. AR = aortic regurgitation; LA = left atrium; LCC = left coronary cusp; LVOT = left ventricular outflow tract; NCC = noncoronary cusp; PG = pressure gradient; RCC = right coronary cusp; SOV = sinus of Valsalva; STJ = sinotubular junction.
The 29-mm THV was prepared with an extra 7-mL volume on the side port of the stopcock that was connected to another inflator. We initially deployed the THV with the extra 5-mL of volume, resulting in robust valve anchorage albeit with moderate paravalvular leakage (PVL). Therefore, postdilatation with an extra 2 mL (total 7 mL) of volume was subsequently performed (Figure 1C, Video 2). After the postdilatation, the PVL was reduced to mild with no occurrence of transvalvular leakage (Figure 1D, Video 3). The postprocedural mean pressure gradient of 9 mm Hg and aortic regurgitation index of 31.3 were acceptable (Figure 1E).
TTE before discharge also showed mild PVL with a mean pressure gradient of 4.9 mm Hg. Postprocedural CT revealed the THV stent area of 787.1 mm2 at the annulus level (22.9% smaller than native annulus size) without leaflet thrombosis (Figure 1F, Video 4). The patient was discharged after an uneventful recovery. At the 6-month follow-up, TTE showed good prosthetic hemodynamics with only mild PVL, and the patients had no cardiovascular symptoms.
Considering the limited sizes of the THVs, a balloon-expandable valve is the most feasible option for TAVR in extra-large aortic annuli because the valve diameter can be expanded by increasing the inflation volume. Although the feasibility of the balloon-expandable valve for large aortic annuli had been previously demonstrated,1,2 none had patients with tricuspid aortic valve with annuli >1,000 mm2.3 We report a successful case of TAVR for tricuspid aortic stenosis with the largest reported annulus by the extra 7-mL volume overfilling of the current-generation balloon-expandable valve; the improved sealing skirt could have contributed to mitigate PVL, albeit with the expanded stent frame smaller than the annulus.
Funding Support and Author Disclosures
Dr Ishizu is the proctor of intracardiac echocardiography during TAVR for Johnson and Johnson. Dr Shirai is the proctor of transfemoral-TAVR for Edwards Lifesciences, Medtronic, and Abbott Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Preoperative Contrast-Enhanced CT
Postdilation Performed With 7 mL Overinflation
Aortography After Postdilation
Postoperative Contrast-Enhanced CT
References
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Supplementary Materials
Preoperative Contrast-Enhanced CT
Postdilation Performed With 7 mL Overinflation
Aortography After Postdilation
Postoperative Contrast-Enhanced CT