‘Valve-in-valve’ implantation in a patient with degenerated aortic bioprosthesis and severe regurgitation

A 70-year-old man was admitted due to dyspnoea (NYHA class III). In 1989, he underwent an aortic valve replacement using a Carpentier–Edwards bioprosthesis no. 21 and a left internal mammary artery–left anterior descending coronary bypass. In 2003, a laryngectomy and post-operative radiotherapy were performed because of laryngeal cancer. He then decided to stop smoking. At admission, blood pressure was 121/50 mmHg, and a murmur and peripheral signs of severe aortic regurgitation were noted. Transthoracic and transoesophageal echocardiography showed degeneration of the bioprosthesis with severe regurgitation due to cusp prolapse, left ventricular ejection fraction of 50%, and systolic pulmonary artery pressure at 60 mmHg (Panel A). The coronary angiogram showed three-vessel disease with a patent graft. The patient was formally denied surgical valve replacement because of high risk of mediastinitis due to laryngostomy and the impossibility of double thoracotomy due to radiation skin disease. In addition, the mortality risk predicted by the EuroSCORE was 35%.