Snared From The Jaws Of Defeat: A Case Of TAVR Valve Migration When Treating Aortic Insufficiency
Ryan Azarrafiy, MD, MPH, Morgan H. Randall, MD, Michael R. Massoomi, MD, Thomas M. Beaver, MD, MPH.
University of Florida, Gainesville, FL, USA.
Transcatheter aortic valve replacement (TAVR) is rarely employed for aortic sufficiency (AI) as it poses unique technical difficulties particularly in seating of the valve due to the absence of significant calcification. We present a high-risk surgical case with mild calcification and severe insufficiency that was treated with TAVR and complicated by valve migration into the ventricle. We describe our intraoperative solution to obtain an excellent result.
A 69-year-old female presented to the hospital with dyspnea on exertion and progressive lower extremity edema. Her history included a mitral valve repair eight years prior, atrial fibrillation, heart failure with an ejection fracture (EF) of 25-30%, and a recent admission for anemia of unknown etiology. Echocardiogram demonstrated severe AI, severe left ventricular (LV) dysfunction, and moderate right ventricular (RV) dysfunction. She was discussed at multidisciplinary conference and was considered for a clinical trial of a novel aortic valve for AI but was screened out due to her EF. We decided to pursue TAVR using a self-expanding valve. She was taken to a hybrid operating room where a 29 mm self-expanding valve was placed in the aortic annulus. However, after complete deployment, the valve migrated into the left ventricle creating severe AI and impinging the anterior leaflet of the mitral valve. This led to mitral stenosis and moderate mitral regurgitation. The valve delivery system was then replaced with a 14 French sheath. Two "goose neck" snare devices were introduced and utilized to secure the commissural tabs on the valve for retraction. Simultaneously pulling both snares enabled us to maneuver the valve into position before gradually re-releasing the valve.
Transesophageal echocardiogram confirmed excellent positioning with no significant regurgitation or perivalvular leak. The patientís course was uncomplicated, and she was discharged on postoperative day 3. She described marked improvement in her symptoms at follow up.
Treating AI with TAVR poses unique challenges and complications. Our case highlights the difficulty of the procedure and the limitations of current technology. We offer a feasible solution to valve migration utilizing snares to achieve a positive clinical outcome.
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