Homograft aortic root replacement is a surgical technique used in complex aortic surgery such as acute aortic dissection, infective endocarditis, and in aortic valve reoperation. Typically the conduit becomes heavily calcified and makes redo surgery a technically challenging option.
Case description
A 55-year-old man was referred to our institution for refractory heart failure. He first underwent mechanical aortic valve replacement (AVR) in 1975. In 2002 in the context of a type A aortic dissection he had redo AVR, consisting of an aortic homograft and stentless aortic root repair.
Echocardiography showed severe aortic regurgitation in the absence of significant stenosis secondary to a degenerated aortic valve (Supplementary material online, Video S1). Computed tomography and transoesophageal echography confirmed the sealed type A aortic dissection (Figure 1).
Figure 1.
Computed tomography showing a heavily calcified aortic root with sealed aortic dissection.
The patient was turned down from further surgical intervention due to the high risk of reoperation with a calcified degenerated homograft. Therefore, we planned percutaneous transcatheter aortic valve replacement (TAVR) using the self-expandable ACURATE NEO LARGETM valve. Reaching the aortic valve was difficult due to the large aortic dissection (Supplementary material online, Video S2). However, an optimal final position was obtained for the TAVR (Supplementary material online, Video S3). Immediate improvement in haemodynamic parameters was observed. Echocardiography confirmed the result of the procedure (Supplementary material online, Video S4). The patient was discharged at Day 4.
Discussion
In conclusion, percutaneous TAVR is feasible in aortic homograft failure using a self-expandable valve. Failure rates of aortic homograft are between 10% and 25% at 15 years and nearly 50% by 20 years.1 In the literature, balloon-expandable TAVR technology has been reported to treat degenerated aortic homograft valves in both an open heart2 and a percutaneous3 approach. The ACURATE NEOTM valve offers a novel technology to tackle the challenges associated with this procedure. Further studies are needed to see if it can reduce the risk of annular rupture (associated with balloon-expandable valve) or valve migration (associated with self-expandable valves) which can complicate TAVR in homograft intervention.
Supplementary material
Supplementary material is available at European Heart Journal - Case Reports online.
Consent: The author/s confirm that written consent for submission and publication of this case report including image(s) and associated text has been obtained from the patient in line with COPE guidance.
Conflict of interest: none declared.
Supplementary Material
References
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