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Transcatheter Aortic Valve Replacement
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remodelled or stretched, but not fractured, include Trifecta (Abbott), Carpentier-Edwards standard and supra-annular (Edwards Lifesciences), Inspiris (Edwards Lifesciences) and, Perimount 2700 (Edwards Lifesciences) [15, 27]. Surgical valves that cannot be fractured or remodelled include the Hancock II (Medtronic) and Avalus (Medtronic) surgical valves. Stentless and suture less valves can be remodelled but not fractured [92].
An achievable increase in internal valve diam­eters of up to 3–4 mm in 19–21 mm surgical valve has been demonstrated on invitro testing with up to 6mm increase in inner diameter with ≥27mm valve [125, 126]. The size of balloon to be used should be determined by the true inner diameter of the SHV, anticipated increase in size of the valve, location of the coronary arteries (VTC) and anatomy of the aortic root [125, 126]. The aortic root and LVOT should be carefully accessed for calcication and although usually debrided [125, 126] if present the procedure should be avoided [98].
Procedural associated complications include THV damage and embolization, coronary artery obstruction, annular rupture, mitral valve injury [92, 125, 126], VSD [125, 126], hemodynamic instability, accelerated leaet degeneration and leaet tearing [92]. A new surgical valve (Inspiris Resilia, by Edwards Lifesciences) has inherent ability to expand during VIV TAVR thereby accommodating a larger TAVR valve [92].
Diagnoses andPreprocedural Assessment
Trans Thoracic Echocardiography
Surgical bio prosthesis in situ with moderate val­vular regurgitation. Reversal of ow in the distal aortic arch during diastole with a mean transval­vular gradient of 15 mmHg, peak velocity of
2.7 m/s AVA, VTI 2.3 cm2 and VTI indexed at
1.1 cm2/m2. The left ventricle is normal in size with normal systolic function. Concentric remod­eling with septal attening present. The aorta shows normal sinus of Valsalva (index at 16mm/ m2; 33 mm). Ascending aorta measures 43 millimeters.
CT Planning forTAVR
The patient had a 27mm Magna Ease with pros­thetic leaet thickening and the bio prosthesis appears canted (Figs. 46 and 47). Simulating a 26mm THV the VTC was 10mm at the LM and 4mm at the RCA (Fig. 48) A STJ dimension of 35×35mm and the surgical posts did not reach the STJ.The dimension at the sewing ring was 26mm. There was mild calcication of the proxi­mal dilated ascending aorta which measured 42mm×41mm. There was horseshoe calcica­tion in the right ilio femoral system however in the presence of a minimum diameter of 8mm and lack of signicant tortuosity access was deemed feasible. Left sided femoral access not feasible due to bulky severe calcication.
Fig. 46 27mm Magna Ease visualised on preprocedural CT with the sewing ring diameter measuring 26.9mm
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Fig. 47 Degenerative valve changes with leaet calcication
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Fig. 48 Simulating a 26mm THV (a) VTC was 10mm at the left main coronary with the (b) stent post extending above the left main coronary ostium. (c) The VTC mea-
sures 4mm at the RCA with the (d) stent post at the level of the right coronary artery
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Dierential Diagnosis
The patient’s symptoms were attributed to heart failure with moderate aortic regurgitation. Myocardial ischemia was excluded with normal troponins and a non-ischemic ECG pattern. Pneumonia was excluded in the absence of pyrexia and normal inammatory markers. There were no features or biochemical markers to sug­gest a pulmonary embolism. A possible prosthetic leaet vegetation as the cause of AR was sus­pected on TEE however this was excluded on CT.The nal diagnoses was a failed SAVR with clinical deterioration.
Heart Team Approach andDiscussion
In view of the patient’s acute clinical decline sec­ondary to acute aortic insufciency in a failed 27 mm Magna Ease a decision was made to replace the aortic valve. Considering his co mor­bidities and high surgical risk, percutaneous transcatheter heart valve in valve procedure with the possibility of balloon valvuloplasty was planned.
Intra andPost Procedural Assessment
Following routine right sided trans femoral access, the implanted surgical aortic valve was
crossed with a J-wire then exchanged for an extra stiff wire. The prosthetic valve was then cracked with a 26 mm non-compliant balloon (Fig. 49) Immediately thereafter the patient became hypo­tensive due to leaet tear and torrential AR.The Sapien 3 was rapidly advanced and deployed under rapid pacing with good results. Haemodynamic stability was restored, and the procedure continued and completed uneventfully.
Immediate post procedural trans thoracic echocardiogram demonstrated a well seated trans catheter aortic heart valve in surgical valve with a peak velocity of 2.5m/s and a mean gradi­ent 12 mmHg. There was no valvular or paravalvular regurgitation. No pericardial effu­sion was present and left ventricular function was normal without a shunt.
Thirty-day transthoracic echocardiogram demonstrated a well seated TAVR valve with a valve area of 1.5cm2, peak velocity of 2.6m/s, VTI 1.5cm2 and a mean gradient of 12mmHg. No valvular prosthesis regurgitation and trivial paravalvular regurgitation was present. LVEF was low normal at 52%.
Post procedure CT demonstrated an S3 in Magna Ease in good position and adequately expanded (Fig. 50) without coronary artery obstruction (Fig. 51).
abc
Fig. 49 Intra procedural uoroscopy demonstrates (a) balloon dilatation to fracture surgical valve. (b) Deployment of TAVR (S3) into fractured SAVR. (c) Post TAVR deployment contrast injection suggests good position
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Fig. 50 Post procedure CT demonstrates an S3in Magna in good position and adequately expanded
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Fig. 51 Orthogonal views demonstrating good expansion and no coronary artery obstruction
Clinical Controversies andPearls
• Pre-TAVR valvuloplasty may either increase the rate of PVL (due to reduced prosthetic valve anchorage) or reduce the rate of PVL due to more circular TAVR valve expansion and reduction of under-expansion.
Key Points
– Balloon valvuloplasty has been used more
commonly following the advent of TAVR.
– Intraprocedural balloon sizing of the
annulus provides complementary infor­mation when CT sizing of the annulus is borderline between two valve sizes.
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– Balloon valvuloplasty inated to a size
similar to the predicted TAVR valve and aortography of the root can help deter­mine risk of coronary artery occlusion.
– Although leaet laceration during valvu-
loplasty is rare, mortality is high at 41%.
Chapter Review Questions
Aortic Stenosis
1. What are the factors to be considered and
reported on during the pre-procedure TAVR to reduce the risk of coronary artery
obstruction? A. Coronary ostial height B. Sinus of Valsalva diameter C. Leaet heights D. Aortic root dimensions E. Choice of prosthetic valve F. All of the aboveAnswer: F
Explanation: A combination of coronary ostial height (concerning if less than 12mm) and Sinus of Valsalva diameter (<30mm pre­dicts risk of coronary artery occlusion). Additional considerations include leaet heights, aortic root dimensions and choice of prosthetic valve.
Any accessory coronary artery and sepa­rate ostium of the any coronaries must be identied and assessed for risk of occlusion.
Bicuspid Aortic Valve
2. Which of the following complications are NOT more likely in TAVR of Bicuspid aortic valves?
A. Malposition B. Paravalvular regurgitation C. Device migration/embolization D. Pacemaker requirements E. Peripheral vascular injury F. Annular rupture
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Answer: E
Explanation: Ascending aortic dilatation
and aortopathy is more common in patients with bicuspid aortic valves, however there is no higher risk for peripheral vascular injury in patients with bicuspid aortic valves.
Aortic Regurgitation
3. Which of the following is NOT a feature of severe AR on TTE?
A. Ratio of regurgitant jet width to LVOT
width ≥65%.
B. Regurgitant volume >50mL and regurgi-
tant fraction ≥60%. C. Effective regurgitant orice area ≥0.3cm2. D. A vena contracta >0.6cm. E. All the above. F. None of the aboveAnswer: B
Explanation: Regurgitant volume >60mL and regurgitant fraction ≥50% are indicative of severe aortic regurgitation.
Valve inValve
4. Which of the following statements about valve in valve procedures is INCORRECT?
A. The incidence of coronary artery obstruc-
tion is higher for valve in valve compared to native aortic TAVR.
B. When implanted into a stented biopros-
thetic valve the THV displaces the leaets of the degenerated bioprosthetic valve into an open position forming a covered cylinder.
C. In stentless valves, the coronary ostial
heights and Sinus of Valsalva dimensions are determined as per the native valve
D. Obstruction occurs more commonly in
stented valves compared to stentless valves.Answer: D
Explanation: Obstruction occurs more commonly in stentless valves which are usu­ally utilized in small aortic roots.
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Valvuloplasty
5. Which of the following is not a contraindica­tion to the aortic balloon valvuloplasty
A. Presence of severe AS. B. Presence of infective endocarditis C. Presence of LV thrombus D. Presence of signicant left main coronary
artery stenosis
E. None of the above
Answer: A
Explanation: Aortic balloon valvuloplasty
is contraindicated in the absence of severe AS.
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