CASE REPORT
A 70-year-old woman presented with worsening dyspnea [NewYork Heart
Association (NYHA) Class III] after she had received a Sorin Perceval
S (21 mm) surgical bioprosthetic tissue valve due to severe aortic valve
stenosis six year ago. She had also undergone VVI pacemaker implantation
after SAVR due to postoperative permanent complete atrioventricular
block. Transthoracic echocardiography (TTE) revealed severe valvular
aortic regurgitation with associated stenosis (mean gradient: 35 mmHg).
Both paravalvular and central components of aortic regurgitation and
stenosis were detected during echocardiographic examination (Figure 1).
Cardiac computed tomography (CT) scan fluoroscopic images demonstrated
that some part of the Perceval® S valve collapsed and
protruding into LV outflow. No prosthesis displacement was detected
(Figure 2). Because of the current status of the patient, a percutaneous
VIV procedure was planned by the heart team instead of a re-do surgical
procedure. Size selection was based on both computed tomography scan and
the available information within the Valve-in-Valve Aortic application
(version 2.0)
The procedure was performed using the right transfemoral approach under
mild anesthesia. The first percutaneous ballooning of the sutureless
prosthesis was performed with an 18 mm balloon. Aortic root angiography
during balloon inflation did not show potential coronary obstruction
risk before device implantation as the inflated balloon simulates the
displacement of the leaflets of the sutureless prosthesis. Although
sufficient expansion of the Perceval® S valve was
obtained during the balloon inflation, immediate recoil with a similar
pre-balloon appearance of the bioprosthesis was noted. Portico® 23 mm
valve (St. Jude Medical Inc., St.Paul, MN, USA) was advanced to the
surgical prosthesis level but failed to cross the bioprosthesis.
Therefore, balloon dilatation with a larger balloon (20 mm) was
performed. Then, the transcatheter valve was implanted adequately at the
lowest visible margin of the Perceval® S valve stent
(Figure 3). Since there was still significant paravalvular aortic
regurgitation postimplant, a 22 mm balloon was inflated within the newly
implanted transcatheter self-expandable valve. There was still mild to
moderate aortic regurgitation with no significant aortic valve gradient
(Figure 4). Two days later, a single-chamber ventricular pacemaker was
upgraded to a dual-chamber pacemaker. The post-procedural course was
uneventful, and symptoms and NYHA class improved significantly. TTE at
discharge showed mild to moderate aortic valve regurgitation and no
significant gradients across the aortic VIV. The patient was still in
good condition without any complication after 1 year of follow up.