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.