Case 1
A 68-year-old male with ischemic cardiomyopathy, status post left ventricular assist device (LVAD), presented with symptoms of progressive shortness of breath and fatigue due to moderate-to-severe aortic insufficiency. The patient was assessed and considered prohibitive risk for aortic valve replacement by the Heart Failure Team and referred for TAVR evaluation. A transthoracic echocardiogram was done, showing left ventricular dysfunction with an ejection fraction of 10% and severe aortic insufficiency concerning for closed-loop recirculation (Figure 1).
We chose a Medtronic 34 mm Evolut with the goal of properly oversizing the native annulus. Since the valve was unable to provide a sustainable fix to the existing insufficiency, the LVAD flow was regulated during the procedure to avoid displacement of the bioprosthetic valve into the left ventricle by the existing regurgitation. At that point, we decided to place a #29 size Balloon-expandable Edwards SAPIEN 3, oversizing it by adding an extra 4cc to the nominal valve volume and deploying it as a VIV within the aforementioned Medtronic Evolut valve. The overexpansion of the SAPIEN 3 Valve made it possible to anchor both valves in a non-calcified annulus (Figure 2). Postoperatively, a transesophageal echocardiogram showed an improved left ventricular ejection fraction of 15%, a mean pressure gradient of 2.2 mmHg, and a LVOT diameter of 2 cm. There were no complications from the procedure and excellent hemostasis was obtained. Patient was discharged home postoperative day 3. On further follow up, the patient felt significantly better and was extremely pleased with the results.