Next Article in Journal
Blick Zurück Auf Grosse Ärzte, Ihre Taten und die Folgen
Previous Article in Journal
Amiodarone and the "Dizzy" Patient
 
 
Cardiovascular Medicine is published by MDPI from Volume 28 Issue 1 (2025). Previous articles were published by another publisher in Open Access under a CC-BY (or CC-BY-NC-ND) licence, and they are hosted by MDPI on mdpi.com as a courtesy and upon agreement with Editores Medicorum Helveticorum (EMH).
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Interesting Images

Percutaneous Treatment of a Degenerated Transcatheter Heart Valve

by
Stefan Toggweiler
*,
Miriam Brinkert
,
Matthias Bossard
,
Florim Cuculi
and
Richard Kobza
Luzerner Kantonsspital, Herzzentrum, Kardiologie, 6000 Lucerne, Switzerland
*
Author to whom correspondence should be addressed.
Cardiovasc. Med. 2018, 21(10), 262; https://doi.org/10.4414/cvm.2018.00579
Submission received: 17 July 2018 / Revised: 17 August 2018 / Accepted: 17 September 2018 / Published: 17 October 2018

Case history

A 68-year-old man presented with increasing shortness of breath and a history of decompensated heart failure 8 years aher transfemoral implantation of a CoreValve 29 mm for severe, calcified aortic stenosis. Transthoracic and transoesophageal echocardiography revealed a partial tear-off and prolapse of one of the bioprosthetic leaflets of the CoreValve, with severe transvalvular and mild paravalvular regurgitation and a mild stenosis with a mean gradient of 26 mm Hg (Figure 1A). The patient’s main comorbidity was a congenital Laurence-Moon-Bardet-Biedl syndrome with blindness and obesity (body mass index 49 kg/m2). The patient was on rivaroxaban for persistent atrial fibrillation. Coronary angiography showed patent coronary arteries but a very shallow aortic sinus with a substantial risk of coronary obstruction (Figure 1B). In the presence of negative blood cultures and an unremarkable positron emission tomography (PET) scan, active endocarditis was very unlikely.
The patient was discussed in the interdisciplinary HeartTeam. The decision was to repeat the transcatheter aortic valve implantation with an Allegra transcatheter heart valve (THV) (NVT AG, Muri, Switzerland and NVT GmbH, Hechingen, Germany). Before implantation of the Allegra, a 22-mm TrueDilatation balloon was inflated and a supra-annular injection was performed to ensure patency of the coronary arteries (Figure 1C). Thereaher, an Allegra 27 mm was implanted about 6 mm below the inflow portion of the CoreValve (Figure 1D). Postdilatation was performed with the 22-mm TrueDilatation balloon. Postprocedural course was uneventful. Echocardiography before discharge showed a mild paravalvular leak and a mean gradient of 18 mm Hg; the calculated aortic valve area was 1.7 cm2.

Discussion

There is a growing body of evidence for transcatherter aortic valve implantation (TAVI) in degenerated surgical bioprostheses [1]. However, only a few cases of TAVI in a degenerated TAV have been reported, a condition that we may see frequently in the near future [2]. Since introduction of the procedure in 2008, the annual numbers of TAVI have rapidly grown in Switzerland, Germany, other countries in Europe and in North America [3]. Moreover, indications have been extended to younger and lower risk patients. Accordingly, a steady increase of TAVI-in-TAV procedures can be anticipated.
Percutaneous treatment of degenerated THVs offers several challenges. The diameter of the THV usually does not equal the nominal diameter of the THV. Furthermore, as in our case, the degenerated THV may be underexpanded. Therefore, preprocedural screening with multidetector-row computed tomography (MDCT) may be of particular importance. As with to percutaneous treatment of degenerated surgical bioprostheses, there may be a substantial risk for coronary obstruction associated with TAVI-in-TAV procedures. A higher implantation of a second THV may extend the sealing skirt of the first THV. The degenerated leaflets of the first THV, which are effectively stented open by the procedure, may further increase the risk for coronary obstruction. The risk may be highest in patients with a shallow aortic root and a supra-annular THV, as in our patient.
Currently, there is no specific recommendation regarding anticoagulation aher TAVI-in-TAV. Our patient was kept on rivaroxaban, which he was taking because of persistent atrial fibrillation. However, many centres now routinely treat all their patients with a vitamin K antagonist or a direct oral anticoagulant for a few months aher TAVI-in-TAV or TAV in a degenerated surgical bioprosthesis.
All of the currently available THVs can be implanted in degenerated THVs, but they all have some limitations. The Allegra has a relatively straight shape, which minimises interference with the frame of the degenerated THV (Figure 2) [4]. In addition, the supra-annular position of the leaflets may result in acceptable gradients even in narrow anatomies or underexpanded THVs. In our patient, other valves may have been less well suited. For example, the height of a Sapien 3 (Edwards Lifesciences, Irvine, USA) may not be sufficient to fully stent a degenerated CoreValve open, especially in the presence of a torn leaflet. Implantation of an Evolut R inside a CoreValve may result in a lot of Nitinol struts inside the aortic sinus and the ascending aorta, resulting in difficult coronary access. Finally, the upper crown of the ACURATE neo (Boston Scientific, Marlborough, USA) may interfere with the frame of the CoreValve, resulting in incomplete expansion. Nevertheless, it may be challenging to access the coronary arteries aher implantation of an Allegra inside a self-expanding valve. In conclusion, this very early experience suggests that the Allegra THV may be well suited for the treatment of degenerated THVs.

Disclosure statement

ST is a consultant and Proctor for NVT GmbH, a consultant and proctor for Boston Scientific/Symetis SA, and has received an institutional research grant from Boston Scientific. The other authors have no relevant conflicts of interest to disclose.

References

  1. Paradis, J.M.; Del Trigo, M.; Puri, R.; Rodes-Cabau, J. Transcatheter Valve-in-Valve and Valve-in-Ring for Treating Aortic and Mitral Surgical Prosthetic Dysfunction. J Am Coll Cardiol. 2015, 66, 2019–2037. [Google Scholar] [CrossRef] [PubMed]
  2. Schmidt, T.; Frerker, C.; Alessandrini, H.; Schluter, M.; Kreidel, F.; Schafer, U.; et al. initial experience at two German centres. EuroIntervention. 2016, 12, 875–882. [Google Scholar] [CrossRef] [PubMed]
  3. Eggebrecht, H.; Mehta, R.H. Transcatheter aortic valve implantation (TAVI) in Germany 2008-2014: on its way to standard therapy for aortic valve stenosis in the elderly? EuroIntervention. 2016, 11, 1029–1033. [Google Scholar] [CrossRef] [PubMed]
  4. Wenaweser, P.; Stortecky, S.; Schutz, T.; Praz, F.; Gloekler, S.; Windecker, S.; Elsasser, A. Transcatheter aortic valve implantation with the NVT Allegra transcatheter heart valve system: first-in-human experience with a novel self-expanding transcatheter heart valve. EuroIntervention. 2016, 12, 71–77. [Google Scholar] [CrossRef] [PubMed]
Figure 1. Implantation of an Allegra valve in a degenerated CoreValve. This patient presented with severe transvalvular aortic regurgitation due to partial tear-off and prolapse of one of the leaflets (A, arrow). The aortic sinus was narrow with a high risk of coronary obstruction (B, arrow). An injection was performed during inflation of a 22 mm balloon to assess patency of the coronary arteries (C, arrow). Final position of the Allegra 6 mm below the inflow portion of the CoreValve (D), with only minimal space (E, arrow) between the frames of the transcatheter valves (E, white dotted line) and the sinus/left main coronary artery (E, yellow dotted line).
Figure 1. Implantation of an Allegra valve in a degenerated CoreValve. This patient presented with severe transvalvular aortic regurgitation due to partial tear-off and prolapse of one of the leaflets (A, arrow). The aortic sinus was narrow with a high risk of coronary obstruction (B, arrow). An injection was performed during inflation of a 22 mm balloon to assess patency of the coronary arteries (C, arrow). Final position of the Allegra 6 mm below the inflow portion of the CoreValve (D), with only minimal space (E, arrow) between the frames of the transcatheter valves (E, white dotted line) and the sinus/left main coronary artery (E, yellow dotted line).
Cardiovascmed 21 00262 g001
Figure 2. The Allegra transcatheter heart valve. The Allegra is a self-expanding transcatheter aortic valve prosthesis that incorporates supraannular bovine pericardial leaflets. Due to the straight shape of the frame, it has the potential to minimise interference with the frame of degenerated THVs.
Figure 2. The Allegra transcatheter heart valve. The Allegra is a self-expanding transcatheter aortic valve prosthesis that incorporates supraannular bovine pericardial leaflets. Due to the straight shape of the frame, it has the potential to minimise interference with the frame of degenerated THVs.
Cardiovascmed 21 00262 g002

Share and Cite

MDPI and ACS Style

Toggweiler, S.; Brinkert, M.; Bossard, M.; Cuculi, F.; Kobza, R. Percutaneous Treatment of a Degenerated Transcatheter Heart Valve. Cardiovasc. Med. 2018, 21, 262. https://doi.org/10.4414/cvm.2018.00579

AMA Style

Toggweiler S, Brinkert M, Bossard M, Cuculi F, Kobza R. Percutaneous Treatment of a Degenerated Transcatheter Heart Valve. Cardiovascular Medicine. 2018; 21(10):262. https://doi.org/10.4414/cvm.2018.00579

Chicago/Turabian Style

Toggweiler, Stefan, Miriam Brinkert, Matthias Bossard, Florim Cuculi, and Richard Kobza. 2018. "Percutaneous Treatment of a Degenerated Transcatheter Heart Valve" Cardiovascular Medicine 21, no. 10: 262. https://doi.org/10.4414/cvm.2018.00579

APA Style

Toggweiler, S., Brinkert, M., Bossard, M., Cuculi, F., & Kobza, R. (2018). Percutaneous Treatment of a Degenerated Transcatheter Heart Valve. Cardiovascular Medicine, 21(10), 262. https://doi.org/10.4414/cvm.2018.00579

Article Metrics

Back to TopTop