23 Dec 2025
When a surgical valve needs a second life
A 79-year-old patient previously treated with surgical aortic valve replacement was referred after an episode of acute cardiac decompensation. Although clinically stabilised, further evaluation revealed degeneration of the bioprosthesis, and mixed aortic valve pathology.
This case focuses on the diagnostic assessment and the strategic considerations guiding the choice of an interventional valve-in-valve approach in a challenging anatomy.
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When a surgical valve needs a second life Challenging session in calcified lesionsCase summary
- A 79-year-old male patient was transferred from a partner hospital
- He had been admitted there 10 days earlier with acute cardiac decompensation
- Due to respiratory insufficiency, he underwent non-invasive ventilation
- He received i.v. diuretics and antibiotics as he developed pneumonia
- He was sufficiently re-compensated at arrival in our facility
- Lab results were normal but NT-proBNP remained significantly elevated, with 2,900 pg/ml
- The patient had undergone surgical aortic valve replacement in 2008 (Perimount 23 mm) due to severe aortic valve stenosis
- He was treated with oral anticoagulants due to persistent atrial fibrillation treated with pulmonary vein isolation in 2022
- He was currently in sinus rhythm
- He had been diagnosed with prostate cancer, that was medically controlled, but had metastasised to the hip
Echocardiography
Moderate to severe aortic valve insufficiency
Moderate aortic valve stenosis
Coronary angiography and CT
coronary sclerosis
Diagnosis
- Cardiac decompensation due to degeneration of surgical aortic valve prosthesis
Risk calculation for re-do surgery
- STS-Score 2.17 for operative mortality
- 15.5 % for morbidity and mortality
Considerations
- Peri-operative risk calculation in favor of interventional approach
- Small root anatomy especially for a male patient
- Low coronary take-off
2 comments
Risk of coronary obstruction and sinus sequestration with self-expanding valve is too high. Annular modification of the Perimount prothesis with True balloon and balloon-expandable valve implantation is the first of possible options. Another one is BASILICA procedure with self-expanding valve implantation, but the risk of sinus sequestration is still high.
Risk of coronary obstruction is high. My steps would be: Balloon modification with 22 mm balloon with aortogram to map the leaflet movement > Coronary protection of high risk (also see the VTC in CT) > BEV 23 mm > IVUS before removing the LCA GC and wire.