Recurrent Valve Migration During TAVR: Using One Valve to Anchor Another Valve

J INVASIVE CARDIOL 2023;35(5):E277-E278.

Key words: transcatheter aortic valve replacement, embolization, Sapien valve

A 75-year-old male with severe symptomatic aortic stenosis and a hypertrophic and hyperdynamic left ventricle (Video 1) underwent TAVR. Annular perimeter and area were 78.7 mm and 472 mm², respectively. Attempts to deploy a 29 mm Evolut-Pro valve at a depth of 5 mm below the annulus (Figure 1A) resulted in migration to the aorta (Video 2), requiring re-sheathing. The valve was finally deployed 16 mm below the annulus, resulting in severe aortic regurgitation (AR) due to location of the entire impermeable skirt within the left ventricular outflow tract (LVOT) (Figure 1B, Video 3). Attempt to implant another identical valve within the first valve at a higher position in order to seal the paravalvular leak by overlapping the device skirts and the annulus¹(Figure 1C), resulted in embolization of both valves to the aorta (Figure 1D, Video 4). The external valve was snared and pulled to aortic arch while the internal valve was re-sheathed and implanted 16 mm below the annulus, resulting in severe AR (Figure 1E, Video 5). A 26 mm Sapien S3 valve was then delivered (Video 6) and implanted within the second Evolut-Pro valve at the level of the aortic annulus, achieving a good hemodynamic result with trivial AR (Figure 1F, Video 7).

We initially selected a repositionable self-expanding valve to enable re-sheathing in case of valve migration,² however valve anchoring within the hyperdynamic and hypertrophic left ventricle was not possible. Deep positioning of the second valve within the LVOT provided an anchor within which the third valve was successfully implanted at an intra-annular position.

Affiliations and Disclosures

From the Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was received for the publication of the images herein.

Manuscript accepted September 26, 2022.

Address for correspondence: Dr Ronen Jaffe, Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal St, Haifa, Israel 34362. Email: jaffe@clalit.org.il

References

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2. Kim WK, Schäfer U, Tchetche D et al. Incidence and outcome of peri-procedural transcatheter heart valve embolization and migration: the TRAVEL registry (TranscatheteR HeArt Valve EmboLization and Migration). Eur Heart J. 2019;40:3156-3165. Epub 2019 Jan 2. doi: 10.1016/j.ijcard.2018.12.079