Valve-in-Valve Transcatheter Aortic Valve Replacement in a High-Risk Patient with a Biocor Bioprosthesis and a Flail Prosthetic Valve Leaflet

An 80-year-old woman with a history of surgical aortic valve replacement with a 21 mm St. Jude Medical Biocor porcine aortic valve 14 years prior presented with New York Heart Association (NYHA) class III symptoms, severe aortic insufficiency from a degenerated prosthesis, and a large echocardiographic mobile mass representing a highly mobile prosthetic leaflet. The patient worsened to NYHA class IV symptoms despite medical management. The Society of Thoracic Surgery mortality risk score was extremely high. However, a valve-in-valve transcatheter aortic valve replacement (TAVR) was found to be a reasonable option. We used a 20 mm SAPIEN 3 Ultra valve (Edwards Lifesciences Inc., Irvine, CA, USA) with a SENTINEL embolic protection device (Boston Scientific, Marlborough, MA, USA). During valve deployment, the echocardiographic mobile mass was visually pinned between the new TAVR valve and the surgical bioprosthetic valve. No large embolic debris was noted within the embolic protection device, and the patient remained without any new focal neurologic deficits in the perioperative period and at the 30-day follow-up. The severe aortic insufficiency resolved, and the patient clinically improved to NYHA class II symptoms.