Recurrent severe aortic stenosis one year after transcatheter aortic valve-in-valve implantation: Successful treatment with balloon aortic valvuloplasty

Abstract

Transcatheter aortic valve-in-valve (VIV) implantation has evolved as one of the primary therapeutic modalities in patients with failed surgical bioprosthesis allowing a reduction in rate of surgical reintervention. We report a case of a 90-year-old woman who had previously undergone aortic valve replacement with 21-mm Carpentier-Edwards valve in 1999 followed by 23 mm Sapien VIV in March 2013. She developed severe recurrent aortic stenosis 1-year post-VIV which was successfully treated with balloon aortic valvuloplasty (BAV). BAV can be a favorable treatment option allowing considerable symptomatic relief and improvement in performance of daily activities in extreme age patients who develop restenosis after VIV implantation and are high-risk candidates for both redo-surgical aortic valve replacement and redo-VIV implantation.

<Learning objective: Transcatheter aortic valve-in-valve (VIV) implantation has become the most utilized surgical alternative in patients with failed bioprosthetic valves. However, known procedural complications include increased risk of coronary obstruction, elevated post-procedural gradients, and risk of valvular restenosis. Balloon aortic valvuloplasty allows significant symptomatic relief and can successfully be performed in patients developing severe symptomatic aortic valve restenosis following VIV implantation.>

Introduction

Since its conception in 2002, transcatheter aortic valve implantation (TAVI) has become the most utilized minimally invasive procedure in patients with severe aortic stenosis who are deemed inoperable or assessed as having high risk of surgical mortality [1]. Following which in recent years valve-in-valve (VIV) implantation has emerged as an acceptable and technically feasible alternative to conventional redo-surgery for bioprosthetic valve dysfunction. Due to the limited durability of the bioprosthetic valves along with increasing number of elderly high-risk surgical candidates, an increasing number of patients are selected to undergo VIV implantation [2]. However, complication profile of this procedure includes high post-VIV transvalvular gradients, potentially life-threatening coronary obstruction, and severe symptomatic recurrent aortic stenosis requiring re-admission which remains a significant challenge in elderly high-risk surgical patients with multiple comorbidities [3], [4]. We report successful treatment and follow-up of a patient treated with balloon aortic valvuloplasty (BAV) after she developed severe aortic valve stenosis 12 months post-VIV procedure.

Case report

A 90-year-old female patient presented with severe progressive shortness of breath, orthopnea, paroxysmal nocturnal dyspnea with oxygen saturation (O₂ sat) of 84% in February 2014. She was started on supplemental oxygen, followed by placement on continuous positive airway pressure. Transesophageal echocardiogram (TEE) showed an increase in velocity to 519 cm/s and gradients to 108/72 mmHg (peak/mean; Fig. 1A), peak velocity ratio of left ventricular outflow tract to aortic valve: 0.2 and valve area: 0.4 cm² (V_max), following which diagnosis of severe recurrent aortic stenosis within 1 year of VIV-implantation was made. Her past surgical history included hysterectomy, cataract surgery, left knee arthroscopic surgery, aortic valve replacement with 21-mm Carpentier-Edwards pericardial valve (Edwards Lifesciences Corporation, Irvine, CA, USA) with aortic annular enlargement with bovine pericardium in 1999 at the age of 76 years, followed by a VIV with 23 mm Edwards SAPIEN XT transcatheter heart valve (Edwards Lifesciences) in March 2013 at our institution.

Fig. 1.

In a patient with restenosis post-transfemoral valve-in-valve (A) transesophageal echocardiogram showing sclerotic leaflets with restricted motion (arrow); (B) transesophageal echocardiogram of Edwards SAPIEN XT valve-in-valve after balloon aortic valvuloplasty shows improved leaflet motion (arrow).

Her echocardiography findings before the transfemoral VIV included symptomatic prosthetic tissue valve aortic stenosis with an annular measurement of 20 × 18, annular area 361 mm², perimeter 67 mm, transvalvular velocity of 502 cm/s, peak/mean gradients of 101/66 mmHg, aortic valve area of 0.3 cm² and aortic valve area index of 0.2 cm/m². Society of thoracic surgeons (STS) risk score was above 15% and European system for cardiac operative risk evaluations II score (EuroSCORE) was 19.2% making her a very high-risk surgical candidate. Following the VIV procedure, peak-to-peak gradient improved from 61 mmHg to 18 mmHg, while transthoracic echocardiography (TTE) findings on post-operative day 1 showed considerable reduction in aortic valve velocity to 330 cm/s, gradients to 44/27 mmHg (peak/mean), improvement in aortic valve area to 0.7 cm² and aortic valve area index to 0.4 cm²/m². Five months after VIV implantation, transvalvular velocity increased to 403 cm/s and gradients increased to 65/39 mmHg (peak/mean). At the current admission, surgery was reconsidered but was determined to be too high risk considering the comorbidities and therefore a decision to proceed with BAV for Edwards Sapien XT valve-in-valve was undertaken. Her pre-BAV TTE findings included peak transvalvular velocity of 519.7 cm/s, peak/mean gradients of 108/72 mmHg, valve area of 0.4 cm², and valve area index of 0.3 cm²/m².

Using modified Seldinger technique, an 8-French (Fr) introducer was advanced in the right femoral artery. A multipurpose diagnostic catheter was then advanced into the aortic root. Using the right anterior oblique (RAO) view and a straight-tipped wire, the multipurpose guidewire was successfully traversed across the Sapien aortic valve into the left ventricle. The straight wire was removed and an exchange length extra-stiff J-wire with a ventricular bend was inserted into the left ventricle. Then, a dual-lumen pigtail was inserted across the valve. Simultaneously hemodynamic parameters were recorded, demonstrating a peak-to-peak gradient of approximately 45 mmHg (mean gradient 43 mmHg). The pigtail was then removed over the exchange length wire and an 18 mm × 3 cm Tyshak balloon (Braun Interventional System Inc., Bethlehem, PA, USA) was advanced across the Sapien valve and deployed successfully (Fig. 2A). The balloon was expanded under rapid pacing conditions with adequate pulse pressure loss (Fig. 2B). Post-BAV echocardiography showed a decrease in peak velocity to 373 cm/s and a decrease in peak/mean gradient to 56/33 mmHg (Fig. 1B). As of November 2015, the patient has been clinically stable, in an overall state of general well-being, and with complete participation in routine home activities; a decision to follow-up with a redo-valvuloplasty would be taken if need be in the near future. Her most recent TTE at 18 months follow-up post-BAV demonstrated a peak velocity of 464 cm/s and gradients of 94/56 mmHg (peak/mean) with a valve area of 0.8 cm² and valve area index of 0.5 cm²/m².

Fig. 2.

Tyshak balloon aortic valvuloplasty: (A) 18 mm × 3 cm Tyshak balloon advanced across the Edwards SAPIEN XT valve; (B) balloon expansion under rapid pacing conditions.

Discussion

Surgical aortic valve replacement involving prosthetic heart valves which are majorly tissue valves have been shown to have a life span of 7–9 years leading to eventual degeneration and failure [5]. Redo-surgery for these failed bioprosthetic valves is associated with significant morbidity and mortality mainly in elderly patients with significant comorbidities. Transcatheter heart valve implantation within a failed bioprosthesis, a “valve-in-valve” procedure, has become the most utilized minimally invasive alternative with clear benefits in such patients [6]. Since our patient was an advanced age 89-year-old female, with the presence of multiple comorbidities such as hypertension, hypothyroidism, and hypercholesterolemia, along with previous history of transient ischemic attack, age-related macular degeneration, and sensorineural hearing loss, we considered VIV as a preferred therapeutic modality in treating the failed aortic valve bioprosthesis.

However, the benefits of VIV over redo-surgical valve replacement go hand in hand with the complication profile which involves elevated post-procedural gradients, life-threatening coronary ostial obstruction and possibility of restenosis over time in patients with small bioprosthesis and predominant surgical valve stenosis [7]. These complications can be avoided or managed with appropriate valve sizing and selection along with pre-procedural imaging [8]. In our case, development of recurrent severe aortic stenosis post-VIV could possibly be related to malcoaptation of the aortic valve leaflets due to the valve prosthesis being larger in size. This could have possibly been avoided with appropriate sizing or the use of supra-annular-type transcatheter aortic valve; however, unfortunately we only had two sizes of Edwards Sapien XT available at that time for surgically inoperable patients in our institution. Another possibility for the restenosis of Sapien valve could be a thrombus [9], [10], although neither transthoracic nor transesophageal echocardiograms showed evidence of a thrombus. Of note, after the initial TAVI procedure using a 23 mm Sapien VIV implant, the patient was started on aspirin 81 mg per oral (PO) daily and clopidogrel 75 mg PO daily. Clopidogrel was discontinued after 6 months but she continued to be on aspirin 81 mg PO daily at the time of presentation.

Considering the advanced age and multiple comorbidities, we decided to proceed with BAV for treating the severe symptomatic post-VIV restenosis. Although her post-BAV transvalvular velocity and pressure gradients remained high, she was able to achieve significant symptomatic relief with successful return to her daily activities. She remains clinically asymptomatic to date, which signifies the importance of BAV as a successful treatment strategy for VIV restenosis in elderly, high surgical risk patients.

Conflict of interest

The authors declare that there is no conflict of interest.