Treating severe restenosis of a 20-mm balloon-expanding valve after a transapical approach with a risk of coronary obstruction
In this challenging redo TAVI case, an 87-year-old woman presented with severe bioprosthetic valve restenosis and advanced heart failure symptoms, eight years after a previous transapical implantation.
Her frailty, prior surgical approach, and complex anatomy—with low coronary heights and a stent frame extending beyond the sinotubular junction—posed a high procedural risk.
Careful evaluation and multidisciplinary discussion were essential to define a safe and effective treatment strategy.
Authors
Background
Valve-in-Valve or redo-TAVI procedures carry a high risk of coronary occlusion, especially in patients with low coronary heights or high stent frames. The Chimney technique is an effective strategy to preserve coronary flow in these cases.
Case presentation
The patient was referred from an external facility for evaluation of suspected severe stenosis of a previously implanted bioprosthetic aortic valve.
She had undergone transapical TAVI in May 2017. Over the past eight years, she developed progressive NYHA class IV symptoms, including dyspnea at rest, orthopnea, and bilateral leg edema.
Physical examination revealed a grade 2/6 midsystolic murmur and bilateral leg swelling. Body mass index (BMI) was 16.9 kg/m² (weight 40 kg, height 154 cm).
Past medical history
The patient underwent transapical TAVI with a 20-mm balloon-expandable valve (Edwards SAPIEN 3) in May 2017 for severe aortic stenosis. No significant coronary stenoses were observed on coronary angiography.
Her medical history was notable for iron deficiency anemia, managed with intravenous iron supplementation, and a cerebrovascular accident in 2016 without residual neurological deficits. Additionally, she had undergone right total hip arthroplasty.
Examination
The patient presents with severe degeneration of a bioprosthetic aortic valve, as confirmed by both transthoracic and transesophageal echocardiography. Hemodynamic assessment demonstrates a peak transvalvular gradient of 84 mmHg, a mean gradient of 49 mmHg, and a peak velocity of 4.59 m/s, consistent with severe aortic stenosis. The left ventricular outflow tract (LVOT) measures 17.3 mm. The aortic valve area (AVA) is calculated at 0.63 cm², with an indexed AVA of 0.47 cm²/m², confirming critical obstruction. Cardiac output is 3.48 L/min, stroke volume index is 56.18 mL/m², and cardiac index is 2.61 L/min/m². Mild aortic regurgitation is also present (Figure 1A), while left ventricular ejection fraction remains within normal limits.
Laboratory testing reveals an elevated NT-proBNP level of 1,662 pg/mL, indicative of increased cardiac wall stress and symptomatic heart failure. Transesophageal echocardiography corroborates severe stenosis with advanced structural degeneration; however, due to pronounced acoustic shadowing and artifact formation, valve planimetry was not feasible (Figures 1B and 1C).
Surgical risk assessment indicates a logistic EuroSCORE I of 41.92 % and a EuroSCORE II of 11.44 %.
Figure 1. Echocardiographic and Transesophageal Echocardiography Findings - (A) Continuous-wave (CW) Doppler on admission. (B) Transesophageal echocardiography (TEE), short-axis view, revealed turbulent flow across the bioprosthetic valve on color Doppler on admission. (C) Transesophageal echocardiography (TEE), long-axis view showing a heavily calcified bioprosthesis on admission.
Computed tomography (CT) provides essential anatomical information. Imaging reveals that the outflow edge of the bioprosthetic stent frame extends beyond the sinotubular junction, resulting in complete coverage of the right coronary artery (RCA) ostium, which measures 11 mm in height. The left coronary artery ostium is located at a height of 14 mm, and the aortic annular height is also 14 mm. These anatomical features indicate a substantial risk of coronary obstruction in the setting of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) (Figure 2).
Figure 2. MSCT Valve Measurements Using the 3mensio Program:
(A) Measurement of the inflow frame area of the 20 mm Sapien 3 TAVR valve. (B) and (C) 3D visualization of the Virtual Valve in a valve-in-valve configuration and assessment of the height of the right coronary artery.
The left common femoral artery measured 6.1 × 6.9 mm, suggesting potential suitability for transfemoral access. In contrast, the right common femoral artery measured 4.2 × 4.9 mm, and the right common iliac artery measured 4.9 mm in diameter. However, the presence of extensive circumferential calcification in the right iliac artery significantly limits its feasibility for vascular access (Figures 3A–B).
Figure 3. MSCT vascular access measurements using the 3mensio software
(A) Measurement and visualisation of the right common femoral artery, right external iliac artery, and right common iliac artery, including a segment of the descending aorta.
(B) Measurement and visualisation of the left common femoral artery, left external iliac artery, and left common iliac artery, including a segment of the descending aorta.
References
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