Successful Aortic Valve Replacement After Transcatheter Aortic Valve Implantation (TAVI) Following Initial Surgical Aortic Valve Replacement (SAVR): A Case Report

Abstract

Patient: Female, 39-year-old

Final Diagnosis: Aortic stenosis

Symptoms: Dyspnea fatigue occasional episodes of near syncope

Clinical Procedure: —

Specialty: Cardiac Surgery

Objective: Unusual clinical course

Background

The management of degenerated bioprosthetic aortic valves poses a significant clinical challenge, particularly in younger patients with a history of rheumatic heart disease. While transcatheter aortic valve replacement (TAVR) has emerged as a less invasive alternative to redo surgical aortic valve replacement (SAVR), its long-term durability and the potential need for subsequent interventions remain areas of concern. This report describes a unique case of a young patient who underwent SAVR after TAVR, following an initial SAVR, highlighting the complexities and therapeutic considerations in managing such cases.

Case Report

A 39-year-old woman with a history of rheumatic heart disease and severe aortic stenosis underwent bioprosthetic aortic valve replacement in 2014. She subsequently required TAVR in 2023 due to valve degeneration. Despite TAVR, she developed recurrent severe aortic stenosis, necessitating a redo SAVR with a mechanical valve in 2024. This report outlines the patient’s clinical course, diagnostic findings, and surgical management.

Conclusions

This case underscores the importance of careful patient selection and long-term follow-up in individuals undergoing aortic valve interventions. It highlights the potential need for subsequent surgical intervention even after TAVR, particularly in younger patients. The successful redo SAVR following TAVR demonstrates the feasibility of this approach in carefully selected cases, despite increased surgical complexity.

Introduction

Rheumatic aortic stenosis in young patients presents a unique and challenging clinical scenario. For high-risk patients, transcatheter aortic valve replacement (TAVR) offers a less invasive alternative to the standard surgical aortic valve replacement (SAVR) for treating severe symptomatic aortic stenosis. However, the long-term durability of TAVR in younger patients and the potential need for subsequent interventions remain significant concerns that are still being actively studied [1,2].

Redo SAVR following TAVR, particularly in patients who previously underwent SAVR, presents additional complexity. As the use of TAVR continues to expand, reports of redo SAVR after failed TAVR are increasing. This procedure carries inherently greater risk and potentially worse outcomes than primary SAVR [3]. This case highlights the clinical decision-making process involved in managing recurrent aortic stenosis in a young patient with a complex history of multiple valve interventions.

Case Report

A 39-year-old woman with a history of rheumatic heart disease and severe aortic stenosis presented with recurrent symptoms, including progressive dyspnea, fatigue, and occasional episodes of near syncope, despite a recent TAVR. She underwent bioprosthetic aortic valve replacement in 2014 for rheumatic aortic stenosis. The bioprosthetic option was selected to avoid long-term anticoagulation in light of her desire for future pregnancy. The specific model and size of the valve implanted during the 2014 SAVR could not be confirmed due to unavailability of historical records.

In 2023, she developed symptomatic degeneration of the bioprosthetic valve, with severe aortic stenosis (AVA 0.9 cm², mean gradient 44 mmHg) and a reduced left ventricular ejection fraction (LVEF) of 25%. Her body surface area (BSA) at the time was 1.99 m². Based on annular measurements, a 23-mm valve was the largest feasible size; however, patient-prosthesis mismatch (PPM) was still anticipated. Given her young age and the elevated surgical risk at the time, a valve-in-valve TAVR using a 23-mm Edwards valve was performed. Immediate post-TAVR suprasternal Doppler imaging revealed a peak/mean gradient of 82/46 mmHg, indicating early PPM.

Despite initial improvement in cardiac function after TAVR, the hemodynamic mismatch likely contributed to early symptom recurrence (Figure 1). Within 1 year, she began experiencing recurrent symptoms of aortic stenosis. Echocardiography in July 2024 revealed a mean gradient of 42 mmHg across the TAVR valve. Transesophageal echocardiography (TEE) confirmed a persistent gradient of 41 mmHg with mild leaflet degeneration. CT angiography demonstrated proper TAVR valve positioning without migration, but persistent stenosis. Laboratory evaluation on admission revealed a mildly elevated white blood cell count (11.8×10⁹/L), low hemoglobin (8.7 g/dL), and elevated INR (2.7), which were attributed to warfarin therapy. Initial transthoracic echocardiography (July 2, 2024) demonstrated an elevated mean gradient of 42 mmHg across the TAVR valve, confirmed by TEE on July 8 as 41 mmHg with mild degeneration. CT aortography on July 9 confirmed proper valve placement without evidence of migration.

Figure 1.

Intraoperative specimen showing the valve-in-valve TAVR configuration, with the transcatheter valve seated within the prior surgical bioprosthesis. The preserved leaflet structure suggests that patient–prosthesis mismatch (PPM), rather than intrinsic degeneration, contributed to the recurrent stenosis.

Because of persistent symptoms and failure to relieve the obstruction, redo SAVR was deemed necessary. The initial TAVR had been chosen as a temporary measure toward eventual surgery. This decision was discussed in the Heart Team meeting, where TAVR was initially favored due to high surgical risk from severe LV dysfunction. This young woman with a rheumatic aortic valve faced complex treatment decisions due to her desire for children and the demands of pregnancy on her heart. Balancing optimal valve management with the safety of future pregnancies presents a significant therapeutic challenge.

The patient was conscious, oriented, and had comfortable and sufficient sleep. There was a well-healed midsternal scar from the previous sternotomy. There was a soft S1, loud S2, and harsh ejection systolic murmur through auscultation involving the base with a radiation to the neck, consistent with severe aortic stenosis. The patient was obese, which further increased the surgical complexity.

Therapeutic Intervention and Treatment Plan

Redo SAVR was recommended based on the patient’s recurrent severe aortic stenosis and the findings from imaging studies. Given the high surgical risk and prior sternotomy, peripheral femoral arterial and venous cannulation was prepared but ultimately not required, as careful sternal re-entry was achieved without major complications. Standard central aortic and bicaval cannulation was used for cardiopulmonary bypass (CPB) initiation. Extensive adhesiolysis was performed using a combination of sharp and blunt dissection to safely mobilize the right ventricle and great vessels. Myocardial protection was achieved using a single-dose of Del Nido cardioplegia administered antegrade and retrograde. The degenerated TAVR valve was surgically removed, and a 21-mm St. Jude Medical Regent mechanical valve was implanted (Figure 2). Postoperative transthoracic echocardiography demonstrated a mean transvalvular gradient of 10 mmHg, with preserved left ventricular ejection fraction (LVEF) of 45–50%. Careful hemodynamic monitoring and support in the ICU – including dobutamine and noradrenaline – were initiated postoperatively and gradually tapered to stabilize the patient’s condition. A postoperative drop in hemoglobin was managed with transfusion of 2 units of packed red blood cells. The use of the Edwards Sapien valve during the prior TAVR strategically minimized trauma to the aortic root. This proved beneficial during the redo surgery, allowing smoother and safer explantation of both prostheses. By reducing manipulation of the aortic root, the need for a more complex Bentall procedure was potentially avoided.

Figure 2.

Intraoperative view during redo surgical aortic valve replacement (SAVR), showing removal of the degenerated TAVR valve. The excised valve demonstrates underlying structural failure, necessitating implantation of a mechanical prosthesis.

Follow-Up and Outcomes

The patient’s postoperative course was remarkably smooth. She was extubated within 24 hours and maintained stable hemodynamics. The surgical wound remained clean and dry, and she was afebrile throughout her hospital stay.

Although TAVR had initially improved her ejection fraction, the presence of patient–prosthesis mismatch (PPM) likely contributed to the recurrence of symptoms. The patient was discharged with instructions for INR monitoring, wound care, and regular follow-up. Discharge medications included bisoprolol, ciprofloxacin, and warfarin, along with thorough education regarding their use and potential adverse effects.

Prior to redo surgery, she had a significantly reduced LVEF of 25%. Postoperative echocardiography confirmed recovery of normal LV function and a well-functioning mechanical valve.

Discussion

This is a unique and challenging clinical case of a young patient who underwent redo SAVR after TAVR, following an initial SAVR. Several interventions were required to manage the complexities associated with her history of rheumatic heart disease and progressive valve degeneration [4,5]. Although hemodynamic data following TAVR and redo SAVR were available and documented, immediate postoperative gradients from the initial SAVR in 2014 could not be retrieved due to the loss of archived records. The decision to proceed with redo SAVR was driven by the patient’s persistent symptoms and imaging evidence of severe aortic stenosis following TAVR.

The long-term durability of TAVR, particularly in younger patients, remains uncertain. While TAVR offers a less invasive option for high-risk individuals, its use in younger populations raises concerns about durability and the potential need for reintervention. TAVR followed by redo SAVR is associated with increased surgical complexity and risks, including injury to surrounding structures and increased bleeding. However, it can be performed successfully in carefully selected patients using meticulous surgical technique [7,8].

Common complications following TAVR include patient-prosthesis mismatch (PPM), particularly in valve-in-valve procedures, occurring in approximately 10–20% of cases [9]. Paravalvular leak occurs in 10–15% of patients [10]. Conduction disturbances – such as new left bundle branch block or atrioventricular block – are observed in 10–20% of cases, with 5–12% requiring permanent pacemaker implantation [11]. Structural valve complications such as thrombosis have an estimated incidence of around 15% in younger patients [12]. As TAVR becomes more common in younger age groups, the balance between procedural benefit and long-term risk must be carefully considered. A summary of the key benefits and limitations of SAVR and TAVR is presented in (Table 1) to aid clinical decision-making, particularly in complex redo cases.

Table 1.

Comparison of SAVR and TAVR: Pros and Cons.

Aspect	SAVR	TAVR
Pros	– Long-term durability (especially with mechanical valves) – Option to excise and repair native valve structures – Suitable for younger patients	– Less invasive – Shorter hospital stay and recovery time – Option for high-risk or inoperable patients
Cons	– More invasive – Longer recovery – Increased risk in redo or frail patients	– Limited long-term durability (especially in younger patients) – Higher risk of PPM in valve-in-valve – Risk of conduction disturbances and pacemaker need

The management of complex aortic valve interventions requires a multidisciplinary approach involving cardiologists, cardiac surgeons, and imaging specialists, as demonstrated in this case. Optimizing outcomes for patients undergoing multiple valve replacements depends on long-term follow-up and rigorous patient selection.

Conclusions

This case demonstrates that redo SAVR following prior TAVR can be both feasible and successful in a young patient with a history of multiple valve interventions. While TAVR offers a less invasive option for high-risk patients, it should be recognized that such patients – particularly younger individuals – may ultimately require subsequent surgical intervention.

The favorable outcome in this case was achieved through a tailored approach, meticulous surgical technique, and comprehensive postoperative care. Further research is warranted to better define the long-term outcomes of TAVR in younger populations and to refine criteria for patient selection in cases requiring redo SAVR after TAVR.