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Successful Transcathether Treatment Of A Detoriated Sutureless Valve Using Self-expandable Prosthesis.
Jan Rychter1, Michał Hawranek2, Tomasz Niklewski1, Mariusz Gąsior2, Tomasz Hrapkowicz1, Michał Oskar Zembala1.
1Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland, 23rd Department of Cardiology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland.

Valve-in-valve (VinV) implantation is an great alternative to reoperation for patients with degenerated bioprostheses and became a method of choice in treatment of bioprosthetic valve degeneration when surgical intervention is associated with increased risk of peri- and postoperative complications. In this case report we describe successful implantation of the Acurate Neo TA transcatheter valve (Boston Scientific, Marlborough, Massachusetts) into a failed sutureless aortic bioprosthesis - Perceval S surgical valve (LivaNova, London, United Kingdom).
80-year-old woman with hypertension, hypercholesterolemia, diabetes, multiple sclerosis, overweight admitted to our hospital because of worsening dyspnoea New York Heart Association Class II/III. Eight years ago she had received a Liva Nova Perceval S (25mm) sutureless valve due to severe aortic valve stenosis. Postoperative echocardiography documented gradients of 31/17 mmHg, and non valvular and paravalvular aortic regurgitation. Current transthoracic echocardiographic assessment revealed severe degenerative changes of valvular prosthesis, elevated transvalvular gradient (peak 70mmHg, mean 43mmHg), moderate aortic regurgitation and slightly reduced ejection fraction to 50. Coronarography showed no significant narrowings in coronary arteries. Computed tomography showed a well-adapted Perceval S prosthesis with an effective annulus diameter 20.8 mm. EuroSCORE II for this patient was 13.11%. The Society of Thoracic Surgery score for reoperation was 9.5%. After reevaluation heart team decision was to made valve-in-valve transcatheter aortic valve implantation. Due to narrow (5.5 mm on right and 5.0 mm on left) severely calcified and turquoise femoral vessels transapical access was preferred over transfemoral approach.
The operation was performed under general anesthesia with standard hemodynamic monitoring. We successfully implanted Acurate Neo size S prosthesis from left mini anterolateral thoracotomy in the fifth intercostal space. Post procedural echocardiography revealed good function of Acurate neo prosthesis with gradient max 32 mmHg, mean 16 mmHg and trivial paravalvular leak. Patient was extubated shortly thereafter and transferred to the intensive care. Five days later the patient was discharged home following uneventful recovery.
The case demonstrates that not only suture-based stented and stentless bioprostheses can be treated by a valve in valve strategy, but it is also feasible to treat a failed sutureless valve using an self-expandable Acurate neo prosthesis.

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