Surgical Removal and Replacement of Chronically Implanted Transcatheter Aortic Prostheses: How I Teach It

Abstract

Dr Mangi discloses a financial relationship with Medtronic and Edwards LifeSciences; Dr Reardon with Medtronic and Boston Scientific.

A case report of open-aorta, direct transcatheter valve-in-valve implantation: an innovative approach to manage the hazard of coronary flow compromise in transcatheter aortic valve re-interventions

“…The potential complications of this procedure are significant, with risks of damage to the aorta or the coronary ostia and with a significant perioperative risk of surgical complications and stroke. 14 , 15 In our evaluation, the hybrid approach selected would have reduced the risk of intra and peri-operative complications, particularly avoiding the technical challenge of removing the stent of the previously implanted transcatheter prosthesis and also simplifying the aortic valve replacement with a direct deployment vs. a surgical implantation. Although more invasive than the traditional transcatheter approach, this hybrid strategy can be the only suitable alternative in those high-risk cases for which TAVI-in-TAV or ViV-TAVI cannot be safely performed because of the risk of coronary flow compromise.…”

“…The aorta was opened transversally above the distal edge of the CoreValve Evolut stent, which was easily palpable through the aortic wall. 15 , 16 The prosthetic valve leaflets, which were diffusely thickened and severely calcified, were excised under direct visualization, leaving in place the prosthetic Nitinol valve frame ( Figure 2 ). A 23 mm Sapien 3 (Edwards Lifesciences Corp, Irvine, CA, USA) was deployed under direct vision warranting control of patency and unobstructed blood flow access to the coronary ostia.…”

Snaring technique for explantation of transcatheter aortic valve bioprosthesis

“…The snaring technique of the transcatheter prosthesis provides the surgeon with a reliable method to maneuver and distract the natural outward radial force of the self-expanding valve during careful dissection. This technique offers a more effective collapse in the prosthesis as compared to using ice-cold saline to allow the nitinol stent frame to collapse on its own, as has been described by others (1). Caution must be exercised to preserve the aortic root and ascending aortic walls to prevent injury, dissection or rupture.…”

TAVR Explantation: Re-Do Risk Without the Re-Do Sternotomy

“…Depending on the underlying dysfunction, TAVR failure can be managed via surgical explantation or with additional transcutaneous intervention, so called valve-in-valve or TAV-in-TAV procedures. [20][21][22] In preparing for the emerging patient population requiring TAVR explant, TAVR failure is a relatively rare occurrence and patient selection for TAVR in younger patient populations is an evolving practice. Given the rarity of TAVR failure and the lack of surgical candidacy in early TAVR-era patients, a majority of cardiac surgeons have limited experience with TAVR explant, which can be technically challenging when time from implantation is greater than or equal to one year due to the neo-endothelialization of the valve into the aortic wall.…”