Valve-in-valve-in-valve: Balloon expandable transcatheter heart valve in failing self-expandable transcatheter heart valve in deteriorated surgical bioprosthesis
Abstract
Valve-in-valve (ViV) procedures for failing bioprostheses carry a certain risk for device malfunction. We herein report a case of a failing Evolut R in a deteriorated Mitroflow, treated with a Sapien 3.
An 81 year old female patient received surgical aortic valve replacement and was treated by ViV due to deterioration. Three years later, echocardiography revealed a pressure gradient of peak/mean 105/63 mmHg. Subsequently, a second ViV procedure with initial intentional rupture of the bioprosthetic stent was performed. Immediate stent recoil of the Evolut R prompted implantation of a Sapien 3. In 30-day follow-up, mean pressure gradient of 30 mmHg and nearly complete symptom relief was documented.
Fracture of a surgical bioprosthetic stent is feasible in a ViV configuration. Supra-annular placement of a balloon-expandable THV as ViV-in-valve is feasible with suboptimal hemodynamic results in this case. Risk of re-do surgery should be weighted against anticipated hemodynamic and clinical results.
CONFLICT OF INTEREST
U. Schaefer is a proctor for Medtronic, is a consultant to Medtronic, and has received lecture fees from Medtronic. L. Conradi is a proctor for Medtronic and proctor, advisory board member and consultant for Edwards Lifesciences. All other authors have nothing to disclose regarding this work.
