Balloon Repositioning of Transcatheter Aortic Valve after Migration into the Left Ventricular Outflow Tract, Followed by Valve-in-Valve Procedure

Abstract

P atients with severe aortic stenosis and coexisting conditions are not good candidates for surgical aortic valve (AV) replacement because they face a high risk of perioperative complications. Transcatheter AV replacement (TAVR) provides a less invasive treatment option for these patients, 1 but the procedure is not without risk. Transcatheter heart valve (THV) migration is a rare but serious TAVR complication that usually occurs during or up to an hour after the procedure.2 Downward migration into the left ventricular outflow tract (LVOT) or left ventricle (LV) is life-threatening and necessitates an urgent bailout procedure; however, such procedures can be complex and may result in serious secondary complications. 3 We report an unusual case of late downward THV migration into the LVOT, which occurred one day after TAVR, and the procedure we used to correct it. Case ReportIn June 2015, an 82-year-old woman with symptomatic, severe aortic stenosis was referred to our hospital for TAVR evaluation. Transthoracic echocardiograms revealed severe aortic stenosis (AV area, 0.93 cm 2 ), a peak pressure gradient of 95 mmHg, a mean pressure gradient of 57 mmHg, an aortic annular diameter of 21 mm, and an LV ejection fraction of 0.85. On multidetector computed tomography (MDCT), the calculated aortic annular area was 3.82 cm 2 (Fig. 1). The patient's risk of operative death was 5.42% according to the logistic EuroScore 4 and 5.3% according to the Society of Thoracic Surgeons score.5 Her Clinical Frailty Scale score was 6. 6The patient underwent TAVR, performed under general anesthesia via a transfemoral approach and with fluoroscopic and transesophageal echocardiographic (TEE) guidance. After confirming the dimensions of the annulus by means of aortography from the perpendicular view, we implanted a 23-mm Edwards Sapien XT valve (Edwards Lifesciences LLC; Irvine, Calif ) with nominal inflation volume under rapid pacing (180 beats/min). After deployment, aortograms revealed good THV expansion and mild aortic regurgitation. Transesophageal echocardiograms revealed several areas of mild paravalvular leakage (PVL) that were not associated with annular calcification (Fig. 2). Aortograms showed that the THV was appropriately positioned at the annulus at the left coronary and noncoronary cusps; however, the THV appeared to be inclined with respect to the annular line. Therefore, we adjusted the C-arm angle to view the THV perpendicularly, and this confirmed that the THV was deployed slightly below the right coronary cusp (RCC) (Fig. 3). We considered performing balloon postdilation but decided not to, because the patient was hemodynamically stable. Accordingly, we completed the routine procedure.The patient remained hemodynamically stable overnight but had an audible systolic murmur the next morning. Transthoracic echocardiograms revealed that the Case Reports

A Rare Complication of Transcatheter Aortic Valve Replacement: Delayed Down Migration of a Portico Valve

“…In previous studies, downward migration to the LVOT after balloon-expandable transcatheter aortic valves has been reported, and some patients have been treated with the valve-in-valve procedure 3 , 4 . However, downward displacement of the self-expanding valve is considered less likely.…”