Does valve-in-valve insertion improve hemodynamics and symptoms in a patient with a degeneratively stenosed CoreValve aortic bioprosthesis?
Valve-in-valve transcatheter aortic valve insertion is a feasible and effective treatment for severe degenerative stenosis of a previously implanted CoreValve bioprosthesis.
BACKGROUND: Transcatheter aortic valve insertion (TAVI) is an emerging therapy in patients at high risk for open heart surgery. The long-term durability of the bioprosthesis is unknown. This is the first report of a severely degeneratively stenosed 2nd generation 26 mm CoreValve(®) aortic bioprosthesis which occurred five and a half years after TAVI. METHODS AND RESULTS: A 92-year-old patient presented with decompensated heart failure NYHA class IV, pulmonary edema, and severe pulmonary hypertension. Echocardiography revealed critical AV-stenosis due to heavily calcified bioprosthetic valve leaflets. Due to high surgical risk with an EuroSCORE of 64.97% and a STS-mortality score of 27.0%, we decided to attempt a valve-in-valve insertion of a 3rd generation CoreValve(®) prosthesis of the same size. Following the delicate retrograde passage of the calcified valve with a preformed stiff wire, balloon valvuloplasty of the severely stenosed CoreValve(®) prosthesis under rapid right ventricular pacing was complicated by two balloon catheter ruptures. Insertion of the 3rd generation CoreValve(®) prosthesis of the same size was quite complex but finally it was successfully completed. There was mild periprosthetic regurgitation and significant decrease in transaortic pressure without residual transvalvular gradient immediately after TAVI. Echocardiography and clinical follow-up at 72 hr after TAVI confirmed excellent valve function with a decrease in systolic pulmonary artery pressure from 70 mm Hg to 35 mm Hg, increase in LV-EF from 35% to 45%, and improvement of functional status from NYHA IV to NYHA II. The patient was discharged in good medical conditions at day eight. CONCLUSION: Degenerative stenosis of a CoreValve(®) bioprothesis may be observed during long-term follow-up after successful TAVI for the treatment of severe aortic valve stenosis. A second valve-in-valve insertion appears feasible but may require particular interventional approaches.
Hammerstingl et al. (Wed,) studied this question.