Use of Transcatheter Heart Valve for Improving Outcomes in High-Risk Redo Cardiac Surgery

Valve-in-valve transcatheter aortic valve implantation (TAVI) is a valuable therapeutic option for managing degenerated bioprosthetic valves, particularly in elderly, high-risk patients. However, careful patient selection and thorough anatomical assessment are crucial to ensure the safety and success of the procedure.

This case involved a 77-year-old female with a prior history of a size 25 Trifecta aortic valve replacement performed 10 years earlier. The patient was admitted with acute pulmonary edema and was found to have severe aortic insufficiency, severe mitral regurgitation, a reduced left ventricular ejection fraction of approximately 40 percent, severe pulmonary hypertension, and renal failure.

Given these significant comorbidities, valve-in-valve TAVI was initially considered as a less invasive option. However, pre-procedural computed tomography (CT) angiography revealed a critically important anatomic concern: the coronary ostia were located just 4 mms above the aortic annulus, which significantly increased the risk of coronary obstruction during a percutaneous valve-in-valve procedure.

After thorough evaluation and multidisciplinary heart team discussion, TAVI was deemed unsuitable due to the high likelihood of life-threatening coronary obstruction. Despite the elevated surgical risk, an open surgical approach was chosen.

To reduce cross-clamp time and minimize dissection in a relatively small and challenging aortic root, a surgical valve-in-valve procedure was performed. This involved the implantation of a size 26 balloon-expandable valve following the complete excision of the degenerated Trifecta valve cusps and the removal of circular pannus tissue beneath the valve. The procedure was performed concomitantly with mitral valve repair.

This video highlights the anatomic challenges that contraindicated percutaneous TAVI in this patient and demonstrates the critical importance of identifying the risk of coronary obstruction, especially when degenerated cusps are left in place and may be displaced by a transcatheter heart valve. The surgical valve-in-valve approach, though high-risk, served as a feasible and effective alternative in this complex and high-risk clinical scenario.

Disclosure

Dr. Babazadeh is a paid speaker for Edwards Life Sciences and for Jaffron Biomedicals.

References

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