Valve-in-Valve TAVR in Aortic Homograft Failure
A 57-year-old man with a prior medical history of hypertension, impaired fasting glucose, bicuspid aortic valve (undiagnosed until adulthood), and rheumatic heart disease with reduced left ventricular ejection fraction (LVEF) (22% at the time of presentation) was admitted to the hospital with shortness of breath. Fifteen years prior to his current presentation, the patient was diagnosed with bicuspid aortic valve and severe aortic insufficiency (AI) with reduced left ventricular (LV) systolic function (20%) and underwent a Ross procedure (aortic root replacement with pulmonary autograft). Postoperatively, he developed a large pseudoaneurysm (8 cm at its widest diameter) at the proximal aortic suture line, with communication into the LV outflow tract. He then underwent surgical aortic root replacement with a 23 mm CryoLife homograft (CryoLife, Inc.; Kennesaw, GA), approximately 2.5 months after his initial Ross procedure. At the time of discharge, his LVEF was 20% with mild aortic regurgitation (AR) and moderate pulmonary regurgitation (PR).
The patient did well for the next decade on medical therapy, with his LVEF improving to 55% 12 months after his homograft repair and root replacement. At approximately 4 months prior to the current presentation, the patient was hospitalized with volume overload; transthoracic echocardiogram showed aortic homograft stenosis (mean gradient = 21 mmHg) (Figure 1) with mild-to-moderate aortic regurgitation and LVEF of 26%. The patient was medically managed and discharged home. Over the ensuing months, despite attempts at medical therapy, the patient developed worsening dyspnea on exertion and reduced exercise intolerance. A repeat echocardiogram showed a mean gradient of 23 mmHg across the aortic valve with moderately severe AR (Videos 1-2). Given the patient's reduced LV systolic function (LVEF = 22% at this time) and prolonged QRS (150 ms), it was decided to pursue cardiac resynchronization therapy pacemaker implantation (the patient refused an implantable cardioverter-defibrillator) and subsequently he was also referred to the Heart Team for consideration of transcatheter aortic valve replacement (TAVR). After review by a cardiothoracic surgeon, the patient was felt to have low-flow, low-gradient hemodynamics and was at extreme surgical risk for aortic valve replacement given two prior sternotomy procedures with multiple interventions on his aortic root in the past.
TAVR was thus pursued, with a self-expanding 29 mm Medtronic CoreValve Evolut R (Medtronic, Inc.; Minneapolis, MN) implanted via the transfemoral approach (Figure 2). Post-procedure, the patient developed severe paravalvular leak and intravalvular regurgitation after the valve was noted to migrate into the LV outflow tract (Videos 3-4). A balloon-expandable 29 mm Edwards SAPIEN 3 valve (Edwards Lifesciences, Inc.; Irvine, CA) was subsequently implanted via the transfemoral approach, with excellent result (Figure 3).
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