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A 67-year-old male with symptomatic severe aortic stenosis (Figure 1, top panel) and well collateralized occluded posterolateral RCA was evaluated for surgical aortic valve replacement (SAVR). STS score (4%) stratified to intermediate risk, but preoperative computed tomography (CT) demonstrated a heavily calcified ascending aorta. Given significant common femoral artery atheromatous disease, valve clinic team recommended transapical transcatheter aortic valve implantation (TAVI).
A 29mm aortic bioprosthetic valve was placed without post-dilation. Intraoperative TEE suggested trace to mild aortic insufficiency with good overall valve placement and function (Figure 1, bottom panel). Following discharge, the patient presented to an outside ED with increasing dyspnea and bilateral pleural effusions. TTE suggested paravalvular leak around the prosthetic valve and co-axial disorientation. Confirmatory TEE showed the bioprosthetic had slipped into the left ventricular outflow tract (LVOT) and was partially rotated with significant valve gradient. Aortogram reaffirmed findings (Figure 1, 4 weeks later).
Transcatheter valve-in-valve versus SAVR were contemplated, and SAVR was offered. SAVR with replacement of ascending aorta under deep hypothermic circulatory arrest versus SAVR with balloon occlusion of ascending aorta were planned. Preoperative CT suggested a small area above the sinotubular junction relatively free of calcification. Six weeks from initial surgery, the native valve and TAVI bioprosthetic were explanted –– the aorta was occluded using a 30mL balloon occlusion catheter (Figure 2). The native valve was bicuspid and heavily calcified with a moderately calcified annulus. As anticipated, the transcatheter valve had rotated and slipped into the LVOT. There was minimal connection to the left and non-coronary leaflets. The patient recovered well and was discharged to skilled rehab on postoperative day 10.
Considerations in this case include – role of TAVI in bicuspid aortic valve disease, delayed recognition of transcatheter valve rotation (overreliance on initial TEE), alternative aortic occlusion options for SAVR in ascending aortic calcification.