The Degenerated Bioprosthetic Aortic Valve: Percutaneous Options or Redo-SAVR?
An 82-year-old male patient presented to the echocardiography laboratory for re-evaluation of his aortic valve replacement. The patient has a medical history significant for coronary artery bypass surgery x 3 (left internal mammary artery to the left anterior descending coronary artery [LIMA to LAD], saphenous vein graft to diagonal branch 1 [SVG to Dx1], and saphenous vein graft to posterior descending artery [SVG to PDA]) and bioprosthetic aortic valve replacement in 2006 for severe calcific aortic stenosis. His most recent prior echocardiogram from October 2016, demonstrated moderate prosthetic aortic valve stenosis with a mean transaortic gradient of 34 mmHg and a small anterior paravalvular leak. Other pertinent medical history includes prostate cancer diagnosed in 2004 (treated with chemotherapy and radiation), hypertension, arthritis, and being overweight (body mass index 26.37 kg/m2). The patient is quite active, plays and enjoys senior tennis, works out at the gym, and enjoys long walks. In the last couple of weeks, he has noticed dyspnea on exertion after long walks and had one episode of lightheadedness while walking in New York City, which resolved after a few seconds. Transthoracic echocardiography showed a 23 mm Epic bioprosthetic valve (St Jude Medical, Inc; St Paul, MN) in the aortic position, which appeared to be stable but with leaflet thickening and reduced excursion. A small anterior paravalvular leak was identified, and there was worsening severe prosthetic aortic valve stenosis, with a mean transaortic gradient of 87 mmHg at a heart rate of 55 bpm (Figure 1). Left ventricular and right ventricular size and systolic function were normal without regional variability and an estimated left ventricular ejection fraction of 60%. His electrocardiogram demonstrated sinus bradycardia with first degree atrioventricular block, and voltage criteria for left ventricular hypertrophy. Chest X-ray demonstrated prior median sternotomy with clear lungs bilaterally. Comprehensive metabolic panel, renal function, liver function tests, and complete blood count were all normal. His 30-day Society of Thoracic Surgery-Predicted Risk of Mortality (STS-PROM) score calculated at 2.65%. Cardiac computed tomography (CT) was performed and demonstrated a right and left iliofemoral diameter of 7.1 mm and 7.5 mm, respectively. His bioprosthetic aortic valve was noted to have hypodensities along the leaflets, likely from pannus formation. The measured Hounsfield units were approximately 145 HU (Figure 2). The maximum annulus diameter was 30 mm, and the minimal annulus diameter was 22 mm. These measurements were taken just below the bioprosthetic aortic valve. The mean annulus diameter was 26 mm. The ostial height of the left coronary artery was 15 mm, and the right coronary artery ostial height was 25 mm. His saphenous vein graft was noted to be attached to one of his sternal wires (Figure 3). Coronary angiography demonstrated his LIMA to LAD, SVG to PDA, and SVG to Dx1 were all patent. The patient otherwise was noted to have a 60% stenosis in his native left main and 100% occlusion of his ostial right coronary artery.
What is the best therapeutic option for this patient?