Persistent Native Aortic Valve Function after Transcatheter Aortic Valve Replacement

Abstract

WEBSITE FEATURE

A 59-year-old man who had been treated with radiation for Hodgkin's lymphoma 35 years earlier developed emphysema and symptomatic severe aortic stenosis with New York Heart Association (NYHA) functional class IV symptoms and episodes of near-syncope. After a median sternotomy, the aorta was reported to be unfavorable for clamping, and valve surgery was aborted. Computed tomography of the chest showed severe calcification of the ascending aorta, aortic arch, and aortic valve (Fig. 1). Figure 2 shows the aortic valve leaflets preprocedurally. Transcatheter aortic valve replacement (TAVR) was performed. A 26-mm Edwards SAPIEN® valve (Edwards Lifesciences Corporation; Irvine, Calif) was implanted by means of a transfemoral approach. After valve deployment, transesophageal echocardiograms showed that the native leaflets were displaced against the aortic wall; however, there was persistent opening and closing of the native left and posterior coronary cusps (Fig. 3). In systole, the native aortic valve commissure had an opening of 0.63 cm² as measured by planimetry. There was mild posterior paravalvular regurgitation at this commissure during diastole. The prosthetic valve functioned normally. Despite the appearance of incomplete apposition to the entirety of the aortic annulus, the prosthesis was in stable position with minimal paravalvular regurgitation (Fig. 4). The patient's recovery was uncomplicated. One month later, he was in NYHA functional class II status, and transthoracic echocardiograms showed a well-seated valve with mild insufficiency.

Fig. 1 Computed tomogram of the chest shows extensive calcification of the ascending aorta, aortic arch, and aortic valve. Calcified pericardium is also noted.

Fig. 2 Preprocedural transesophageal echocardiogram shows the native aortic valve leaflets during A) systole and B) diastole.

Real-time motion images are available at www.texasheart.org/journal.

Fig. 3 Transesophageal echocardiograms show the Edwards SAPIEN® aortic valve (arrows) and the native leaflets (arrowheads) A) open in systole and B) closed in diastole.

Real-time motion images are available at www.texasheart.org/journal.

Fig. 4 Transesophageal echocardiogram with color-flow Doppler shows trace-to-mild paravalvular regurgitation through the native valve (arrow) after deployment of the Edwards SAPIEN® aortic valve.

Real-time motion image is available at www.texasheart.org/journal.

Comment

To our knowledge, a significant persistent lumen in a native aortic valve after TAVR has not been reported. Mediastinal radiotherapy is an established risk factor for the development of a variety of cardiovascular diseases that affect the coronary arteries, pericardium, myocardium, conduction system, and myocardial valves.^1,2 The prevalence of radiation-associated cardiac disease is increasing because of prolonged survival after mediastinal irradiation. Aortic stenosis, a less well-understood complication that can occur 15 to 20 years after radiation therapy, is attributed to diffuse fibrosis with or without calcification.³ Conventional surgical aortic valve replacement in patients with radiation-associated mediastinal disease carries increased risk,⁴ and many patients with this condition are considered for TAVR. A better understanding of how TAVR performs in previously irradiated structures is needed.