A combined single-session percutaneous approach of transcatheter PVL closure and valve-in-valve TAVR is feasible and effective for treating mixed-mechanism bioprosthetic aortic regurgitation in high-risk patients.
Abstract Background Concurrent transvalvular regurgitation (TVR) and paravalvular leak (PVL) complicating TAVR is rare, and optimal management is not well described. Case Summary A 74-year-old man with LVEF of 40% and prior TAVR (34-mm Medtronic Evolut) presented eight years post-implantation with NYHA class IV acute decompensated heart failure. Transthoracic echocardiography (TTE) identified severe bioprosthetic aortic regurgitation; transesophageal echocardiography (TEE) delineated concomitant severe TVR and PVL. Computed tomographic angiography (CTA) identified a discrete paravalvular tunnel between two calcific annular nodules. Given prohibitive surgical risk, he underwent single-session transcatheter PVL closure with an Amplatzer ductal occluder followed by valve-in-valve TAVR with an Edwards SAPIEN 3 Ultra RESILIA valve. AR pressure half-time improved from 217 ms to 436 ms, and invasive aortic diastolic pressure normalized from approximately 40 mmHg to 65 mmHg. At 30-day follow up, symptoms had improved to NYHA class II, with trace residual PVL and no TVR on TTE. Discussion To our knowledge, this represents one of the first reported cases of a combined single-session percutaneous approach, consisting of transcatheter PVL closure and valve-in-valve TAVR, to address mixed-mechanism bioprosthetic aortic regurgitation. TEE and CTA are essential for mechanism delineation. A combined transcatheter approach is feasible and effective in high-risk patients.
Armstrong et al. (Sat,) studied this question.