Excision of TAVR and AVR With LVOT Enlargement

This article is part of CTSNet’s series, Perfecting TAVR Removal | Skills Sharpening With Vince Gaudiani. CTSNet Senior Editor Dr. Vince Gaudiani presents nine surgical videos on the technical aspects of aortic valve replacement after TAVR. This series will conclude in three live learning roundtable events scheduled at three different times to accommodate participants in multiple regions of the world. 

This video demonstrates the removal of a four-year-old Evolute transcatheter aortic valve replacement (TAVR), followed by a Manougian left ventricular outflow tract (LVOT) patch enlargement and the placement of a 23 mm surgical aortic valve.  

The patient had an Evolute TAVR in 2019. After an initially good postprocedural course, the valve started to become stenotic, and, after four years, it had a 70 mm gradient and required surgical aortic valve replacement.   

Dr. Gaudiani demonstrated his strategy for removing the TAVR using the handlebar mustache technique. This technique required grasping the cut sides of the valve and peeling it in toward itself to reduce the diameter of the valve, which facilitated removal. After excision of the valve and assessment of the annulus, the surgeons found that the radius was too small for direct valve placement, as this would cause patient-prosthesis mismatch. Therefore, a Manougian LVOT enlargement was performed. 

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