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.