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Mastering Redo Surgery after TAVR: Aortic and Mitral Replacement with Double Patch Repair and Aortic Root Reconstruction in Endocarditis after TAVR

Thursday, January 18, 2024

In this series of videos, Dr. Vincent Gaudiani shares his experience in the new field of surgery after previous TAVR and provides his tips for safely performing redo surgery for a variety of indications including TAVR early and late failure, endocarditis, and when further valve surgery is required.

The patient in this video is an eighty-three-year-old woman who had a 20 mm TAVR for aortic stenosis, but at the same time had significant mitral disease which was not treated due to a high creatinine. She remained very short of breath, so it was necessary to replace the mitral valve. 

Because the patient had undergone a TAVR, the decision was made to open the aorta and remove the TAVR, which was functional. The TAVR was removed with the handlebar moustache technique. Once it was removed, the aortic annulus was opened with the intention of doing a double patch double valve technique, which the authors have done over 100 times previously. A Manougian style incision was made into the anterior mitral leaflet, but then the team decided to also remove the mitral leaflets. 

Next, the aortic valve sutures were placed and the posterior mitral valve leaflet was removed through the aortic annulus. A patch was placed onto the posterior mitral annulus and a tissue mitral valve was inserted through the aorta. Then, a second patch was placed as the mitral valve was sutured onto the atrium anteriorly. This patch was used both to close the atrium and to perform a Manougian aortic root enlargement. The aortic valve was successfully placed and the aorta was closed with the patch enlarging the aortic outflow tract.

This video presents a seventy-seven-year-old man who had a successful TAVR two years prior but then presented with streptococcus endocarditis. The surgeon’s approached the procedure through an upper mini sternotomy with femoral vein venous cannulation. 

Initially, the plan for cardioplegia was for direct coronary cannulation, but the TAVR valve prevented satisfactory engagement of the coronary arteries and thus required removal prior to selective antegrade and cardioplegia. 

Once the TAVR had been removed, further cardioplegia was given and the right coronary artery ostium was inspected. Unfortunately the TAVR and the calcification of the aortic wall, which had become incorporated into the valve, meant that the orifice of this artery had become damaged. Thus, the decision was made to perform an aortic root replacement. It was deemed to be a safer option than hoping that the right coronary artery would remain patent despite this damage.

Next, the proximal right carty was identified, a vein graft was anastomosed to it, and the ostium of the right coronary artery was oversewn. 

A Valsalva tube graft was then used with an Inspiris valve and the left main stem button was anastomosed to the graft. The vein graft was then anastomosed to the valve graft. Finally, the distal anastomosis was performed and the operation was concluded.


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The 20 Sapien is inherently stenotic. We don’t even carry them. Our goal was to restore her and not leave her partially fixed as theTAVR did. What to do in a case like this is what you can do, your skill set. I hope these cases will enlarge that set. Vince

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