Surgical Salvage of Annular Rupture After Transcatheter Aortic Valve Implantation by Conversion Into Annular Enlargement

Figures

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  Figure 1. Calcified Transcatheter Aortic Valve The transcatheter aortic valve replacement protocol computed tomography showed a moderately calcified aortic valve and minimal ascending aortic calcification. LM = left main coronary artery; RCA = right coronary artery; SOV = sinus of Valsalva; STJ = sinotubular junction.

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  Figure 2. Subannular Rupture (A) Investigation of the aortic root revealed a rupture at the base of the noncoronary sinus where noncoronary cusp calcification pierced the annular wall. (B) The transcatheter aortic valve was explanted, and the native aortic valve was excised.

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  Figure 3. Annular Enlargement The incision was taken down to and through the junction of the left and noncoronary cusps and then diverted to the left coronary cusp to the nadir below the left main coronary artery. The annular disruption in the noncoronary cusp was used as part of the enlargement and, thus, extended until the membranous septum. AML = anterior mitral leaflet; LCC = left coronary cusp; NCC = noncoronary cusp.

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  Figure 4. Graft Preparation A 30-mm synthetic polyester graft was split longitudinally, and a patch to match the width of the annular incision was fashioned. This patch was sewn in using 4-0 monofilament along the annular incision and up along the old annulus and aortic wall to above where the new valve would sit.

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  Figure 5. Valve Implantation A 25-mm bioprosthetic valve was placed.

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  Figure 6. Patch The synthetic polyester graft was cut to fit the remaining opening of the aorta. The inferior and superior limbs were closed with running 4-0 monofilament.