CASE REPORT
An 80 years old female admitted to our department in heart failure. In
2011, she underwent an aortic valve replacement with a 19mm St. Jude
mechanical valve (St. Jude Medical, Minneapolis, MN) for severe
symptomatic aortic stenosis. A trans-thoracic echocardiogram and
fluoroscopy, revealed a thrombus on the mechanical valve with an
immobile leaflet, pannus formation and mean gradient of 45mmHg (Fig.1A,
B).
The patient scheduled for urgent redo valve surgery and two coronary
bypasses as she presented critical stenosis at the coronary angiogram.
The decision of using a transcatheter balloon-expanding Sapien-3 valve
(Edwards Lifesciences, Irvine, CA) was determined by the shorter
estimated CPB and XC time in this elderly fragile lady (Logistic
Euroscore II:42.5% ). After completing the bypasses, a 23mm Sapien-3
was implanted intra-annularly under direct vision. However, it was
immediately noticed that the skirt of the Sapien-3 valve was obstructing
the left coronary ostia (Fig. 2A, B). In order to avoid this
complication we gently cut a little piece of the skirt of the valve to
free the coronary ostia (Fig.2C, D). After successful weaning from
cardiopulmonary bypass, the transesophageal echocardiographic
examination revealed an excellent flow on the left main stem and normal
ventricular function with a mean aortic gradient of 8 mmHg (Fig 3). The
patient had an optimal recovery and discharged after 11 days with 3
months of Warfarin and aspirin, followed by DAPT for life. Clinical and
echocardiographic control after 36 months showed excellent flow through
the left coronary ostia and improved ventricular function.