This article is part of CTSNet’s series, Perfecting TAVR Removal | Skills Sharpening With Vince Gaudiani. [3] 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 presents a 77-year-old man who had a successful transcatheter aortic valve replacement (TAVR) two years prior but then presented with streptococcus endocarditis. Dr. Gaudiani approached the procedure through an upper ministernotomy 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, necessitating its removal prior to performing 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, resulted in damage to the orifice of this artery. Thus, the decision was made to perform an aortic root replacement, which was deemed to be a safer option than relying on the right coronary artery to remain patent despite the damage. 

Next, the proximal right artery 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 subsequently anastomosed to the valve graft. Finally, the distal anastomosis was performed, and the operation was concluded. 

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