Transcatheter aortic valve replacement (TAVR) has become the treatment of choice for severe aortic stenosis in symptomatic patients at high or extreme risk for open heart surgery and an alternative to surgical aortic valve replacement in intermediate-risk patients.1 Precise implementation is crucial for optimal procedural and clinical results. We describe a case of self-expanding prosthesis embolization (CoreValve Evolut R, Medtronic, Inc, Minneapolis, MN USA) and present a solution using a second prosthesis to capture the embolized one.
A 66-year-old man with two previous sternotomies for coronary artery bypass grafting and surgical aortic valve replacement presented with a severe symptomatic stenosis of his 27-mm Magna valve (Edwards Lifesciences Corp, Irvine, CA USA). Echocardiography demonstrated a mean transvalvular gradient of 43 mmHg, a peak velocity of 4.1 m/s, a valve area of 0.7 cm2, and a left ventricle ejection fraction of 55%. The Society of Thoracic Surgeons Predicted Risk of Mortality score was calculated at 7.8%. After multidisciplinary heart team evaluation, he was referred for TAVR.
Transcatheter Aortic Valve Replacement #1 and Embolization
The patient underwent TAVR using a 29-mm CoreValve Evolut R self-expanding prosthesis via a right transfemoral approach under conscious sedation. Due the Magna valve's 24 mm inner diameter, the TAVR prosthesis was implanted low (Fig. 1A) to prevent overcompression; however, this deployment resulted in severe paravalvular regurgitation. An attempt was made to reposition the valve by snaring it via contralateral femoral and radial access using Amplatz GooseNeck (Abbott, Minneapolis, MN USA) snares to pull the valve higher and reduce the paravalvular aortic regurgitation (Fig. 1B). This rarely used traction method caused the valve to embolize into the ascending aorta (Fig. 1C), and because of aortic arch narrowing and grade 4 plaque, it was impossible to pull the valve into the descending aorta for surgical removal.
Transcatheter Aortic Valve Replacement #2 and Capture
Throughout the procedure, the patient remained hemodynamically stable, so instead of undertaking emergent surgery, an endovascular solution was sought. A second 29-mm CoreValve Evolut R was introduced through the same transfemoral sheath, positioned in the aortic annulus, and 75% deployed in proper position without paravalvular leak (Fig. 1D). Then, using the snares, the first valve was advanced so that its proximal edge covered the unreleased distal edge of the second valve. The second valve was released with its large distal portion just inside the narrower proximal portion of the first valve. Distal tabs of the second valve captured the first one, pinning it in place (Fig. 1E). Completion aortography revealed a stable valve position without extravasation, dissection, or aortic regurgitation. Transthoracic echocardiography demonstrated stable valve position and function (Supplemental Video, Supplemental Digital Content 1, http://links.lww.com/INNOV/A212), and the patient was in New York Heart Association class 1 at 1-year follow-up.
Our case of self-expanding TAVR prosthesis embolization was managed using a strategy employing the distal end of a second valve to capture the proximal end of the embolized one (Fig. 2). We believe that this strategy offers an excellent alternative to open ascending aortic surgery in cases where an embolized prosthesis can be snared but cannot be pulled into the descending aorta.
Published rates of improper positioning of self-expanding TAVR valves range from 2.6% to 8.1%.2 In the present case, a 26-mm CoreValve would be too small to implant inside a 27-mm Magna valve, but a 29-mm CoreValve could be overcompressed at its proximal aspect; hence, the preference for lower implantation to align the Magna valve with a narrower point in the CoreValve. However, low deployment can lead to paravalvular leak3 because the narrower supra-annular portion of the valve does not reach the aortic wall at the level of the annulus. Low deployment is also associated with worsening of mitral regurgitation due to interaction with the anterior mitral leaflet and atrioventricular conduction disturbances.4 A low valve deployment may be treated with endovascular snares to reposition the valve or with deployment of a second valve at a higher position inside the first.3,5
High deployment increases the risk of valve embolization, which has been reported to occur as frequently as 0.5% to 8.0% of the time.6,7 A particular risk factor for high deployment is excessive cardiac output because of inadequate ventricular pacing or premature ventricular contraction.8,2 Treatment of embolization into the aorta has traditionally relied on repositioning the valve into the descending aorta using endovascular snares or removal via open surgery.8,9 Other strategies have included repositioning the valve using a valvuloplasty balloon or deploying a large stent inside the embolized valve to hold the leaflets in the open position.10 Patients with prosthesis embolization have a high risk of mortality11 and morbidity including stroke,7 occlusion of major arteries,7 and aortic dissection12 associated with manipulation of the prosthesis in the ascending aorta.
To date, there exist no guidelines for management of valve embolization. Of course, it is optimal to prevent prosthesis embolization in the first place by employing optimal pre- and intraprocedural imaging to facilitate prosthesis sizing and deployment as well as rapid ventricular pacing if necessary to control cardiac output.
When a self-expanding TAVR valve embolized into the ascending aorta, a second valve was deployed so that its distal tabs captured the proximal portion of the first valve. This technique for management of prosthesis embolization should be considered as an alternative to surgery when aortic anatomy prevents withdrawal of an embolized prosthesis into the descending aorta.
1. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation
2. Al Ali AM, Altwegg L, Horlick EM, et al. Prevention and management of transcatheter balloon-expandable aortic valve malposition. Catheter Cardiovasc Interv
3. Piazza N, Schultz C, de Jaegere PP, et al. Implantation of two self-expanding aortic bioprosthetic valves during the same procedure-Insights into valve-in-valve
implantation (“Russian doll concept”). Catheter Cardiovasc Interv
4. Mangla A, Gupta S. Vascular complications post-transcatheter aortic valve procedures. Indian Heart J
5. Ussia GP, Barbanti M, Ramondo A, et al. The valve-in-valve
technique for treatment of aortic bioprosthesis malposition: an analysis of incidence and 1-year clinical outcomes from the Italian CoreValve registry. J Am Coll Cardiol
6. Dahdouh Z, Roule V, Lognone T, et al. Aortic annulus rupture during transcatheter aortic valve implantation (TAVI): one ounce of prevention is worth one pound of cure. Heart Lung Circ
7. Tay EL, Gurvitch R, Wijeysinghe N, et al. Outcome of patients after transcatheter aortic valve embolization
. JACC Cardiovasc Interv
8. Masson JB, Kovac J, Schuler G, et al. Transcatheter aortic valve implantation: review of the nature, management, and avoidance of procedural complications. J Am Coll Cardiol Intv
9. Chakravarty T, Jilaihawi H, Doctor N, et al. Complications after transfemoral transcatheter aortic valve replacement
with a balloon-expandable prosthesis: the importance of preventative measures and contingency planning. Catheter Cardiovasc Interv
10. Larion S, Moore JR, Ammar C, et al. TEVAR rescue of an embolized Edwards SAPIEN XT valve following TAVR. J Endovasc Ther
11. Gutsche JT, Cheung AT, McGarvey ML, et al. Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg
12. Patrice Mwipatayi B, Nair R, Papineau JL, et al. A difficult case of retrieval of an aortic valve and balloon during a transcatheter aortic valve implantation. Int J Surg Case Rep