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Clinical Images

Successful Valve-in-Valve Replacement Using Intravascular Lithotripsy for Femoral Access in an Elderly Patient With Critical Aortic Stenosis and Extensive Vascular Calcification

Borja Rivero-Santana, MD1,2; Guillermo Galeote, MD, PhD1; Alfonso Jurado-Roman, MD, PhD1,2; Santiago Jiménez-Valero, MD, PhD1,2; Ariana Gonzálvez-García, MD1; Raul Moreno, MD, PhD1,2

September 2024
1557-2501
J INVASIVE CARDIOL 2024;36(10). doi:10.25270/jic/24.00123. Epub May 20, 2024.

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An 87-year-old man with a history of heart failure and a modified bio-Bentall Mitroflow 23-mm bioprosthesis (Sorin) was referred to our institution for critical aortic stenosis, which was confirmed by transesophageal echocardiography. Pre-procedural computed tomography revealed slightly calcified bioprosthesis leaflets, adequate coronary ostia height, and a slightly angled Bentall tube graft measuring 29 mm in diameter at the aortic anastomosis (Figure A).

Considering the high surgical risk (EuroScore II 17.8%), a valve-in-valve procedure was deemed necessary. The femoral access was compromised by extensive calcification and an infrarenal aneurysm with a thrombus extending into both femoral arteries (Figure B and C). To address this, intravascular lithotripsy was performed using a Shockwave medical device, which delivered 5 cycles of 30 pulses via a 7- x 60-mm balloon to the right common femoral artery (Figure D, Video 1). A 20- x 40-mm Atlas Gold balloon (BD) was then advanced through the right femoral artery sheath to crack the Mitroflow aortic bioprosthesis (Figure E). Subsequently, a 23-mm ALLEGRA transcatheter valve (Biosensors) was implanted into the degenerated bioprosthesis, resulting in a mean valve gradient reduction to 3 mm Hg with no significant insufficiency (Figure F, Video 2). No intraoperative complications occurred. The delivery system was removed, and femoral access was closed using a MANTA 18-French vascular closure device (Teleflex) (Video 3). The patient was discharged without complications.

This image underscores the pivotal role of advanced imaging in facilitating valve-in-valve interventions for high-risk patients with restricted access, showcasing the precise procedural execution and highlighting minimal postoperative recovery.

 

Figure.  Comprehensive imaging in valve-in-valve intervention.
Figure. Comprehensive imaging in valve-in-valve intervention. (A) The pre-procedural computed tomography scan showed aortic annulus measurements and detailed dimensions of the Mitroflow bioprosthesis (Sorin). (B) The iliofemoral overview revealed extensive calcification and severe tortuosity, with detailed measurements of each iliofemoral segment. (C) A detailed view of the right iliofemoral system (snake view), highlighting the presence of an intramural thrombus at the infrarenal aorta level (asterisk). (D) Intra-procedural image of the right common femoral artery with a 7.0-mm IVL balloon inflated to 4 atm, demonstrating the intervention process (arrow = balloon, asterisk = femoral head). (E) Fluoroscopic guidance during the valve-in-valve procedure showed the Mitroflow prosthesis fracture with a 20- x 40-mm Atlas Gold balloon (BD) inflated at 16 atm. (F) The final image of the transcatheter valve implantation showed adequate expansion and placement of the ALLEGRA valve (Biosensors). LC = left coronary sinus; NC = non-coronary sinus; RC = right coronary sinus.

 

 

Affiliations and Disclosures

Borja Rivero-Santana, MD1,2; Guillermo Galeote, MD, PhD1; Alfonso Jurado-Roman, MD, PhD1,2; Santiago Jiménez-Valero, MD, PhD1,2; Ariana Gonzálvez-García, MD1; Raul Moreno, MD, PhD1,2

From the 1Cardiology Department, La Paz University Hospital, Madrid, Spain; 2La Paz University Hospital, IdiPAZ Research Institute, Madrid, Spain.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the procedures described in this manuscript.

Address for correspondence: Borja Rivero-Santana, MD, La Paz University Hospital. Paseo de la Castellana 261, 28046. Madrid, Spain.  Email: Borja.riversa@gmail.com; X: @Borja.Riversa