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Clinical Images

Valve-in-Valve Implantation to Seal Post-Dilation-Induced Annular Rupture in Transcatheter Aortic Valve Replacement

Kun Wang, MB1; Yiming Qi, MB2,3;Wenzhi Pan2,3

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Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates. 


J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00092. Epub May 13, 2024.


Aortic annular rupture is a serious complication of transcatheter aortic valve replacement (TAVR). Emergency cardiac surgery repair is the traditional treatment of choice, however, it is associated with high mortality. Here, we report a case of annulus rupture post-balloon dilation during TAVR, which was sealed successfully with the valve-in-valve implantation technique.

An 85-year-old woman was admitted to our hospital with severe symptomatic aortic stenosis. Preoperative computed tomography and transesophageal echocardiography (TEE) revealed a type I bicuspid aortic valve (aortic annulus diameter: 26 mm; Figure 1, Videos 1 and 2). After pre-dilation with an 18-mm balloon (Figure 2A, Video 3), a 26-mm self-expandable Taurus valve (PEIJIA Medical) was deployed (Figure 2B, Video 4). After valve expansion, post-dilation was performed using the 18-mm balloon (Figure 2C, Video 5). Aortography post-dilation indicated middle paravalvular leakage (Figure 2D, Videos 6 and 7), and the patient’s hemodynamics became unstable. TEE revealed cardiac tamponade and tissue swelling around the left sinus, with extensive calcification bulging out during post-dilation (Figure 3, Videos 8 and 9). Despite pericardial fluid drainage, autologous blood transfusion, and antagonizing anticoagulation (Figure 2E), the pericardial fluid increased in volume. After a second 26-mm valve was implanted within the first prosthesis (Figure 2F, Video 10), the patient’s hemodynamics stabilized. TEE revealed no increase in pericardial effusion and a decrease in the paravalvular leak (Video 11). Thus, valve-in-valve implantation may be an effective treatment to seal post-dilation-induced annular rupture during TAVR.

 

Figure 1
Figure 1. Preoperative computed tomography showing (A) the type I bicuspid aortic valve with a 26-mm aortic annulus diameter; images at (B) 2, (C) 4, (D) 6, and (E) 8 mm above the annulus; and (F) several calcification masses. RC = right coronary cusp; LC = left coronary cusp; NC = non coronary cusp.
Figure 2
Figure 2. X-ray images during transcatheter aortic valve replacement showing (A) the pre-dilation, (B) valve morphology after the first valve implantation, (C) the post-dilation, (D) middle paravalvular leakage, (E) drainage of the pericardial fluid, (F) and successful implantation of the second valve.
Figure 3
Figure 3. Transesophageal echocardiography during the transcatheter aortic valve replacement showing (A) the baseline image, (B) calcification around the left sinus after the first valve implantation, (C) extensive calcification bulging out during the post-dilation (red arrow), (D) pericardial effusion (red arrow), (E) swelling of the tissue, and (F) successful implantation of the second 26-mm valve with no increase in pericardial effusion.

 

Affiliations and Disclosures

From the 1Zhuhai People's Hospital, Zhuhai hospital affiliated with Jinan University, Zhuhai, Guangdong, China; 2Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China; 3National Clinical Research Center for Interventional Medicine, Shanghai, China.

Drs Wang and Qi contributed equally to the manuscript.

Consent statement: The authors confirm that informed consent was obtained from the patient for the procedure(s) described herein.

Funding: The present study was supported by the Medical Science and Technology Research Fund of Guangdong Province (grant no.: A2021089).

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

Address for correspondence: Wenzhi Pan, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 200032, China. Email: peden@sina.com.


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