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.