Open Implantation of a Transcatheter Aortic Valve via Redo Sternotomy, Mitral Valve Replacement, and Tricuspid Valve Repair in a High-Risk-Patient [1]
The patient, a 60-year-old male, had previously undergone aortic root replacement due to aortic insufficiency and a bicuspid valve. He suffered from increasing exertional dyspnea. Echocardiography revealed recurrent severe aortic insufficiency, secondary moderate-to-severe mitral insufficiency with marked leaflet tenting, and severe tricuspid insufficiency (pulmonary artery pressure: 70 mmHg). His medical history included heart failure with reduced ejection fraction (HFrEF) (ejection fraction 37 percent), Child-Pugh Class B liver cirrhosis of ethyltoxic origin, acute-on-chronic kidney failure, but no coronary artery disease.
The following surgical approaches were discussed: repeated root replacement, conventional valve replacement, or transcatheter aortic valve implantation (TAVI) combined with a transcatheter edge-to-edge (TEER) procedure. The pros and cons are outlined in this video.
Following a median redo sternotomy, pericardial adhesions were dissected. Standard cannulation of the ascending aorta and bicaval venous cannulation were performed, and the heart was arrested using cold crystalloid Bretschneider cardioplegia. The root prosthesis was heavily calcified and showed perforated cusps. The left and right coronary cusps were excised, while the noncoronary cusp was preserved as additional anchoring for the prosthesis. Afterward, the anterior mitral leaflet was excised, and a 31 mm bioprosthesis was implanted in a standard fashion. Due to the marked leaflet tenting, no repair attempt was undertaken. A 29 mm transcatheter prosthesis was prepared upside down on a transapical delivery system. The valve was inserted into the left ventricular outflow tract (LVOT) at the desired depth, and the balloon was inflated with a nominal volume to implant the valve. Video-assisted inspection of the LVOT confirmed the proper positioning of the prosthetic valves without obstruction. After a total cross-clamp time of 80 minutes, a tricuspid valve repair with a 36 mm Contour ring was performed on a beating heart, aiming for mild residual regurgitation as a decompression for the right ventricle. The right atrium was closed, and the heart was weaned from cardiopulmonary bypass (CPB).
The patient was transferred to the ICU under moderate catecholamine support and extubated the same day. Catecholamines were discontinued on the second postoperative day, and he was discharged on the eighth day after an uneventful course.
Final echocardiography confirmed good function of all valves, with no paravalvular leakage and only mild tricuspid regurgitation, along with a marked reduction in pulmonary artery pressure.
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