Very Late Migration of Balloon-Expandable Transcatheter Aortic Valve

J INVASIVE CARDIOL 2018;30(4):E28-E30.

Key words: transcatheter aortic valve replacement, TAVR, Sapien valve, valve migration, valve-in-valve

A 70-year-old woman was re-admitted to the emergency department with recalcitrant heart failure symptoms that had initially abated following initiation and optimization of diuretic therapy. Past medical history was significant for heart failure with preserved ejection fraction, chronic obstructive pulmonary disease, and aortic stenosis treated with transcatheter aortic valve replacement (TAVR) 3 years prior, with a 23 mm Edwards Sapien XT valve (Edwards Lifesciences). Physical exam was remarkable for bibasilar crackles, 3/6 pansystolic murmur heard best at the apex with radiation to the axilla, and 3/6 harsh, diastolic decrescendo murmur heard best at the lower left sternal border. Transthoracic echocardiogram showed severe mitral regurgitation (MR) with an eccentric posterolateral jet and moderate aortic regurgitation (AR) with peak velocity of 3.8 m/sec, mean gradient of 32 mm Hg, and valve area of 1.2 cm². Three-dimensional transesophageal echocardiogram (3D-TEE) demonstrated two MR jets (Figure 1) and severe AR. There was a migrated aortic prosthesis below the native aortic valve leaflets (Figure 2). In addition, the displaced prosthesis may have disrupted the mitral subvalvular apparatus, leading to a flail P1 scallop. These findings were confirmed by inversion mode volume-rendered and multiplanar gated computed tomographic (CT) reconstruction (Figure 2E; Videos 1 and 2). A valve-in-valve TAVR was planned. Intraprocedural cone-beam CT imaging and aortic root angiogram showed the “slipped” Sapien XT valve (in comparison with the aortic root angiogram from 3 years ago) with severe AR, respectively (Figure 3). There was complete resolution of severe AR following valve-in-valve TAVR with a 23 mm Edwards Sapien 3 valve (Figure 4;  Videos 3-5).

Video Series available here.

From the Heart Valve Service, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas; and Weill Cornell Medical College, New York, New York. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Chinnadurai is an employee (research scientist) at Siemens Medical. Dr Reardon reports advisory board income from Medtronic. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript accepted September 15, 2017. 

Address for correspondence: Ankur Kalra, MD, FACP, FACC, FSCAI, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Weill Cornell Medicine, 6565 Fannin Street, Houston, TX 77030. Email: kalramd.ankur@gmail.com