Redo AVR and Tricuspid Replacement After Previous Mitral Replacement and TAVR 

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. 

A 75-year-old patient had undergone a transcatheter aortic valve replacement (TAVR) eight years prior, and Dr. Vince Gaudiani replaced her mitral valve five years ago. However, she developed severe aortic regurgitation from the TAVR and developed tricuspid regurgitation as well.  

Thus, he performed femoral cannulation, followed by a redo sternotomy, and opened the aorta after administering retrograde cardioplegia.  

The TAVR was removed using the handlebar moustache technique after cutting the TAVR vertically from the left and noncoronary cusp positions. A biological aortic valve replacement was then sutured into the aortic position.  

The roof of the right atrium was accessed to reach the tricuspid valve, and the right ventricular lead was removed from her pacemaker. The tricuspid valve was rheumatic and was replaced with a 29 mm biological valve while completely preserving its leaflets. Notably, Dr. Gaudiani made a good point of ensuring that the struts of the valve were positioned in the annulus, as this was initially not the case with this patient.  

The atrium and aorta were then closed, and the patient was safely separated from bypass.  

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