Back to 2025 Thoracic Abstracts
Valve-in-valve Tavi With Complications In A Degenerated Bioprosthesis: Challenges In Management And Surgical Bailout
Svend Filip Eng1, Mari-Liis Kaljusto
1, Tonje Amb Aksnes
2, Ahmed Ibrahim Al-Ali
2, Morten Svalebjørg
3, Gry Dahle
1.
1Oslo University Hospital, Department of Cardiothoracic surgery, Oslo, Norway,
2Oslo University Hospital, Department of Cardiology, Oslo, Norway,
3Oslo University Hospital, Department of Anesthesiology, Oslo, Norway.
BACKGROUND: We report a complex case of valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) in a degenerated bioprosthetic valve, highlighting diagnostic misinterpretations, procedural complications, and subsequent surgical challenges. The importance of accurate preoperative planning, multidisciplinary decision-making, and the potential risks associated with ViV-TAVI in previously implanted bioprosthetic valves are demonstrated.
METHODS: An 81-year-old male with a history of biologic surgical aortic valve replacement in 2019 presented with symptomatic moderate aortic stenosis due to valve degeneration. Initial records erroneously identified the implanted valve as a different bioprosthetic model, leading to incorrect assumptions regarding its fracture properties. A ViV-TAVI procedure was performed, during which the first prosthetic self-expanding valve was implanted in the correct position. However, during the postdilatation phase, before any high pressure attempt at fracturing the valve, the balloon became entrapped in the valve structure. This resulted in displacement of the newly implanted valve distally into the ascending aorta. A second self-expandable valve was successfully implanted in the correct position. The following day, the displaced valve was surgically retrieved.
RESULTS: The displaced valve was removed via aortotomy in deep hypothermic circulatory arrest (DHCA) and retrograde cardiopulmonary bypass(CPB) the next day. However, after weaning from CPB, the aorta ruptured posteriorly necessitating a second pump run in DHCA and a supracoronary graft was used to replace the ascending aorta to manage the rupture. Unfortunately, the patient developed a major stroke and died on postoperative day nine. Key challenges included:
- Misinterpretation of bioprosthesis type, resulting in an inappropriate fracture attempt.
- Migration of the prosthetic valve requiring surgical retrieval.
- Aortic perforation complicating surgical repair and necessitating multiple DHCA cycles for graft placement and hemostasis.
CONCLUSIONS: This case highlights the critical need for accurate preprocedural imaging and bioprosthetic valve identification in ViV-TAVI procedures. Misinterpretation of valve properties can result in life-threatening procedural complications, requiring surgical bailout. Multidisciplinary planning and preparedness for complex surgical interventions are essential in managing high-risk patients. This case illustrates the challenges of advanced aortic repair and hemostasis in reoperative settings.
Real time fluoroscopy demonstrating the embolized TAVI valve distally in aorta ascendens. The annular valve is in correct position.
Back to 2025 Thoracic Abstracts
