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International Society For Minimally Invasive Cardiothoracic Surgery

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Case Redo Transapical Valve In Valve Tavi
Abdullah S. Alotaibi, Michael Chu, Pantelis Diamatouros, Gil Gelinas, Ray Fujii, Bob Kiaii.
London Health Sciences, Western University, London, ON, Canada.

OBJECTIVE: Valve in valve transcatheter aortic valve implantation (TAVI) has been used to treat degenerated bioprosthetic aortic valves after surgical replacement. TAVI as a procedure has been around for 10 years now. It is expected that we will be seeing patients with degenerative TAVI Valves. We present a case of degenerative TAVI valve with a redo transapical Valve in Valve TAVI. To our knowledge, this is one of the first cases reported in the literature.
METHODS: Case report
RESULTS: This is an 83 years old female with known history of coronary artery disease and calcification of her ascending aorta. She underwent a single vessel coronary bypass graft and transapical TAVI back in 2009. After 9 years, presented with recurrent episodes of congestive heart failure. She was found to have evidence of valvular degeneration of her TAVI valve. CT scan showed severe and irregular calcified atherosclerosis involving both iliac arties, which originally precluded her from a safe vascular access utilizing a transfemoral approach. Hence, the decision to proceed with redo Transapical valve-valve implantation. Under general anesthetia the patient was intubated and prepped in normal fashion. Over the previous submammary incision, another incision was made. Adhesion were taken down. The apex of the heart was identified. The pericardium was opened and the left anterior descending coronary artery was identified. 2 sutures of 0 Prolene pledgets were placed circumferentially around the previous pledgets site creating 2 pursestings. The apex was then puncture and a wire was passed through the TAVI valve and advanced all the way to the descending aorta. The TAVI delivery system was advance to position. On rapid ventricular pacing, the valve was reimplanted within the pervious TAVI valve. The new TAVI valve was implanted in an excellent position. There were no paravalvular leaks and the gradients were a peak of 12 mmHg and a mean of 8 mmHg. Hemostasis was achieved and the patient was closed. Discharged home on the fifth post-operative day. 6 weeks post her operation performing at NYHA class II.
CONCLUSIONS: Redo Transapical valve in valve TAVI is feasible. Using the previous apical delivery site is safe.

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