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Journal of Cardiology Cases 14 (2016) 35–37

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Journal of Cardiology Cases


journal homepage: www.elsevier.com/locate/jccase

Case Report

Recurrent severe aortic stenosis one year after transcatheter aortic


valve-in-valve implantation: Successful treatment with balloon aortic
valvuloplasty
Abbasali Badami (MBBS)a, Entela B. Lushaj (MD, PhD)a, Kurt Jacobson (MD)b,
Amish Raval (MD)b, Lucian Lozonschi (MD)a, Takushi Kohmoto (MD, PhD)a,*
a
Division of Cardiothoracic Surgery – Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
b
Division of Cardiovascular Medicine – Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

A R T I C L E I N F O A B S T R A C T

Article history: Transcatheter aortic valve-in-valve (VIV) implantation has evolved as one of the primary therapeutic
Received 1 September 2015 modalities in patients with failed surgical bioprosthesis allowing a reduction in rate of surgical
Received in revised form 12 February 2016 reintervention. We report a case of a 90-year-old woman who had previously undergone aortic valve
Accepted 9 March 2016
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
Keywords: with balloon aortic valvuloplasty (BAV). BAV can be a favorable treatment option allowing considerable
Valve-in-valve
symptomatic relief and improvement in performance of daily activities in extreme age patients who
Aortic stenosis
Balloon
develop restenosis after VIV implantation and are high-risk candidates for both redo-surgical aortic
Valvuloplasty valve replacement and redo-VIV implantation.
Transcatheter aortic valve 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.>
ß 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Introduction this procedure includes high post-VIV transvalvular gradients,


potentially life-threatening coronary obstruction, and severe
Since its conception in 2002, transcatheter aortic valve symptomatic recurrent aortic stenosis requiring re-admission
implantation (TAVI) has become the most utilized minimally which remains a significant challenge in elderly high-risk surgical
invasive procedure in patients with severe aortic stenosis who are patients with multiple comorbidities [3,4]. We report successful
deemed inoperable or assessed as having high risk of surgical treatment and follow-up of a patient treated with balloon aortic
mortality [1]. Following which in recent years valve-in-valve (VIV) valvuloplasty (BAV) after she developed severe aortic valve
implantation has emerged as an acceptable and technically stenosis 12 months post-VIV procedure.
feasible alternative to conventional redo-surgery for bioprosthetic
valve dysfunction. Due to the limited durability of the biopros- Case report
thetic valves along with increasing number of elderly high-risk
surgical candidates, an increasing number of patients are selected A 90-year-old female patient presented with severe progressive
to undergo VIV implantation [2]. However, complication profile of 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 echocar-
* Corresponding author at: Division of Cardiothoracic Surgery, University of
Wisconsin School of Medicine and Public Health, 600 Highland Avenue, Madison,
diogram (TEE) showed an increase in velocity to 519 cm/s and
WI 53792, USA. Tel.: +1 608 262 3858; fax: +1 608 263 0547. gradients to 108/72 mmHg (peak/mean; Fig. 1A), peak velocity
E-mail address: kohmoto@surgery.wisc.edu (T. Kohmoto). ratio of left ventricular outflow tract to aortic valve: 0.2 and valve

http://dx.doi.org/10.1016/j.jccase.2016.03.013
1878-5409/ß 2016 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.
36 A. Badami et al. / Journal of Cardiology Cases 14 (2016) 35–37

In a patient with restenosis post-transfemoral valve-in-valve (A)


transesophageal echocardiogram showing sclerotic leaflets with
Fig. 1. restricted motion (arrow); (B) transesophageal echocardiogram of
Edwards SAPIEN XT valve-in-valve after balloon aortic valvuloplasty
shows improved leaflet motion (arrow).

area: 0.4 cm2 (Vmax), following which diagnosis of severe recurrent


Tyshak balloon aortic valvuloplasty: (A) 18 mm  3 cm Tyshak balloon
aortic stenosis within 1 year of VIV-implantation was made. Her Fig. 2. advanced across the Edwards SAPIEN XT valve; (B) balloon expansion
past surgical history included hysterectomy, cataract surgery, left under rapid pacing conditions.
knee arthroscopic surgery, aortic valve replacement with 21-mm
Carpentier-Edwards pericardial valve (Edwards Lifesciences Cor-
poration, Irvine, CA, USA) with aortic annular enlargement with
bovine pericardium in 1999 at the age of 76 years, followed by a decrease in peak velocity to 373 cm/s and a decrease in peak/mean
VIV with 23 mm Edwards SAPIEN XT transcatheter heart valve gradient to 56/33 mmHg (Fig. 1B). As of November 2015, the
(Edwards Lifesciences) in March 2013 at our institution. patient has been clinically stable, in an overall state of general
Her echocardiography findings before the transfemoral VIV well-being, and with complete participation in routine home
included symptomatic prosthetic tissue valve aortic stenosis with activities; a decision to follow-up with a redo-valvuloplasty would
an annular measurement of 20  18, annular area 361 mm2, be taken if need be in the near future. Her most recent TTE at
perimeter 67 mm, transvalvular velocity of 502 cm/s, peak/mean 18 months follow-up post-BAV demonstrated a peak velocity of
gradients of 101/66 mmHg, aortic valve area of 0.3 cm2 and aortic 464 cm/s and gradients of 94/56 mmHg (peak/mean) with a valve
valve area index of 0.2 cm/m2. Society of thoracic surgeons (STS) area of 0.8 cm2 and valve area index of 0.5 cm2/m2.
risk score was above 15% and European system for cardiac
operative risk evaluations II score (EuroSCORE) was 19.2% making Discussion
her a very high-risk surgical candidate. Following the VIV
procedure, peak-to-peak gradient improved from 61 mmHg to Surgical aortic valve replacement involving prosthetic heart
18 mmHg, while transthoracic echocardiography (TTE) findings on valves which are majorly tissue valves have been shown to have a
post-operative day 1 showed considerable reduction in aortic valve life span of 7–9 years leading to eventual degeneration and failure
velocity to 330 cm/s, gradients to 44/27 mmHg (peak/mean), [5]. Redo-surgery for these failed bioprosthetic valves is associated
improvement in aortic valve area to 0.7 cm2 and aortic valve area with significant morbidity and mortality mainly in elderly patients
index to 0.4 cm2/m2. Five months after VIV implantation, with significant comorbidities. Transcatheter heart valve implan-
transvalvular velocity increased to 403 cm/s and gradients tation within a failed bioprosthesis, a ‘‘valve-in-valve’’ procedure,
increased to 65/39 mmHg (peak/mean). At the current admission, has become the most utilized minimally invasive alternative with
surgery was reconsidered but was determined to be too high risk clear benefits in such patients [6]. Since our patient was an
considering the comorbidities and therefore a decision to proceed advanced age 89-year-old female, with the presence of multiple
with BAV for Edwards Sapien XT valve-in-valve was undertaken. comorbidities such as hypertension, hypothyroidism, and hyper-
Her pre-BAV TTE findings included peak transvalvular velocity of cholesterolemia, along with previous history of transient ischemic
519.7 cm/s, peak/mean gradients of 108/72 mmHg, valve area of attack, age-related macular degeneration, and sensorineural
0.4 cm2, and valve area index of 0.3 cm2/m2. hearing loss, we considered VIV as a preferred therapeutic
Using modified Seldinger technique, an 8-French (Fr) introduc- modality in treating the failed aortic valve bioprosthesis.
er was advanced in the right femoral artery. A multipurpose However, the benefits of VIV over redo-surgical valve replace-
diagnostic catheter was then advanced into the aortic root. Using ment go hand in hand with the complication profile which involves
the right anterior oblique (RAO) view and a straight-tipped wire, elevated post-procedural gradients, life-threatening coronary
the multipurpose guidewire was successfully traversed across the ostial obstruction and possibility of restenosis over time in
Sapien aortic valve into the left ventricle. The straight wire was patients with small bioprosthesis and predominant surgical valve
removed and an exchange length extra-stiff J-wire with a stenosis [7]. These complications can be avoided or managed with
ventricular bend was inserted into the left ventricle. Then, a appropriate valve sizing and selection along with pre-procedural
dual-lumen pigtail was inserted across the valve. Simultaneously imaging [8]. In our case, development of recurrent severe aortic
hemodynamic parameters were recorded, demonstrating a peak- stenosis post-VIV could possibly be related to malcoaptation of the
to-peak gradient of approximately 45 mmHg (mean gradient aortic valve leaflets due to the valve prosthesis being larger in size.
43 mmHg). The pigtail was then removed over the exchange length This could have possibly been avoided with appropriate sizing or
wire and an 18 mm  3 cm Tyshak balloon (Braun Interventional the use of supra-annular-type transcatheter aortic valve; however,
System Inc., Bethlehem, PA, USA) was advanced across the Sapien unfortunately we only had two sizes of Edwards Sapien XT
valve and deployed successfully (Fig. 2A). The balloon was available at that time for surgically inoperable patients in our
expanded under rapid pacing conditions with adequate pulse institution. Another possibility for the restenosis of Sapien valve
pressure loss (Fig. 2B). Post-BAV echocardiography showed a could be a thrombus [9,10], although neither transthoracic nor
A. Badami et al. / Journal of Cardiology Cases 14 (2016) 35–37 37

transesophageal echocardiograms showed evidence of a thrombus. [2] Duncan A, Davies S, Di Mario C, Moat N. Valve-in-valve transcatheter aortic
valve implantation for failing surgical aortic stentless bioprosthetic valves: a
Of note, after the initial TAVI procedure using a 23 mm Sapien VIV single-center experience. J Thorac Cardiovasc Surg 2015;150:91–8.
implant, the patient was started on aspirin 81 mg per oral (PO) [3] Gurvitch R, Cheung A, Bedogni F, Webb JG. Coronary obstruction following
daily and clopidogrel 75 mg PO daily. Clopidogrel was discon- transcatheter aortic valve-in-valve implantation for failed surgical bioprosth-
eses. Catheter Cardiovasc Interv 2011;77:439–44.
tinued after 6 months but she continued to be on aspirin 81 mg PO [4] Azadani AN, Jaussaud N, Matthews PB, Ge L, Chuter TA, Tseng EE. Transcatheter
daily at the time of presentation. aortic valves inadequately relieve stenosis in small degenerated bioprostheses.
Considering the advanced age and multiple comorbidities, we Interact Cardiovasc Thorac Surg 2010;11:70–7.
[5] Pibarot P, Dumesnil JG. Prosthetic heart valves: selection of the optimal
decided to proceed with BAV for treating the severe symptomatic prosthesis and long-term management. Circulation 2009;119:1034–48.
post-VIV restenosis. Although her post-BAV transvalvular velocity [6] Latib A, Ielasi A, Montorfano M, Maisano F, Chieffo A, Cioni M, Mussardo M,
and pressure gradients remained high, she was able to achieve Bertoldi L, Shannon J, Sacco F, Covello RD, Figini F, Godino C, Grimaldi A,
Spagnolo P, et al. Transcatheter valve-in-valve implantation with the Edwards
significant symptomatic relief with successful return to her daily
SAPIEN in patients with bioprosthetic heart valve failure: the Milan experi-
activities. She remains clinically asymptomatic to date, which ence. EuroIntervention 2012;7:1275–84.
signifies the importance of BAV as a successful treatment strategy [7] Dvir D, Webb JG, Bleiziffer S, Pasic M, Waksman R, Kodali S, Barbanti M, Latib A,
for VIV restenosis in elderly, high surgical risk patients. Schaefer U, Rodés-Cabau J, Treede H, Piazza N, Hildick-Smith D, Himbert D,
Walther T, et al. Transcatheter aortic valve implantation in failed bioprosthetic
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Conflict of interest [8] Camboni D, Holzamer A, Flörchinger B, Debl K, Endeman D, Zausig Y, Maier LS,
Schmid C, Hilker M. Single institution experience with transcatheter valve-in-
valve implantation emphasizing strategies for coronary protection. Ann
The authors declare that there is no conflict of interest. Thorac Surg 2015;99:1532–8.
[9] Mylotte D, Andalib A, Thériault-Lauzier P, Dorfmeister M, Girgis M, Alharbi W,
Chetrit M, Galatas C, Mamane S, Sebag I, Buithieu J, Bilodeau L, de Varennes B,
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