DISCUSSION
The current standard of treatment for failing or degenerated aortic bioprosthetic valves is re-do surgical operation. However, reoperation carries a significant higher risk of morbidity and mortality. An alternative and less invasive option is the transcatheter VIV operation. Sutureless aortic valve replacement has emerged as an innovative alternative for surgical treatment of aortic stenosis, particularly for patients with higher surgical risk (3). The sutureless design has the potential to improve surgical outcomes by providing a less invasive approach and by decreasing cross-clamp and cardiopulmonary bypass duration (3). However, in our case, the recently implanted Perceval valve was failing with significant regurgitation and stenosis. Inappropriately infolding of the surgical valve was the possible main reason for valve failure other than valve degeneration (4). Because of the small stature of our patient, we decided to implant one size larger valve at the index operation, and it resulted in inappropriate infolding of a sutureless valve stent. Eusanio MD. et al. described a similar case that was treated successfully with a balloon-expandable transcatheter valve (5). Shortly after implantation of the Sorin Perceval valve, significant regurgitation had been noted, and a partially collapsed inflow portion of the Sorin Perceval valve at the noncoronary annulus had been clearly demonstrated by cardiac CT in that case. Likewise, the similar infolded appearance of previously implanted Sorin Perceval valve causing valve regurgitation was detected in cardiac CT of our patient. Another issue worth mentioning is sutureless design of Sorin Perceval bioprosthetic valve. Although the absence of sutures may provide less traumatic surgical intervention and less damage to surrounding tissues, this feature has the potential to complicate transcatheter valve deployment and can cause paravalvular valve regurgitation or valve migration. In our case, more than moderate paravalvular leakage was present after our initial transcatheter valve implantation, and two additional balloon post-dilatations were required to mitigate the paravalvular leakage. Paravalvular aortic regurgitation of failing bioprosthetic tissue valves is generally considered to be inappropriate for VIV therapy. Although there was a significant paravalvular component of aortic insufficiency in our patient, unique deformed geometry of a recently implanted sutureless surgical valve was considered to be amenable to transcatheter VIV therapy with acceptable radial force and post-dilatation if necessary in this case and fortunately ended up with an excellent final result.
In the majority of aortic VIV procedures, balloon-expandable Edwards Sapien/Sapien XT (Edwards Lifesciences, Irvine, Cal.) or self-expandable Corevalve (Medtronic, Minn.) transcatheter valves have been used with favorable early results (6-8) and experience is limited with self-expandable Portico valve. However, in our case, we preferred the Portico valve because of its small size and the unique characteristics of retrievability and respectability.
In conclusion, transcatheter VIV procedures for failing surgical bioprosthetic tissue valves offer an alternative to preoperative surgical valve replacement. In this report, we documented the feasibility of an aortic VIV intervention using a self-expandable Portico valve in a leaking deformed sutureless Perceval® S valve.