Aortic paravalvular Amplatzer plug extractions and valve in valve intentional bioprosthetic valve fracture to eliminate large paravalvular gap with severe leak
Background
57-year-old frail lady with HT, DM, CAD, PAD, remote CVA, Lupus, ESRD on HD, aortic valve disease, s/p SAVR (21mm Magna Ease) and CABG (single SVG to dRCA) in April 2016 with severe paravalvular leak, had 3 Amplatzer vascular plugs placed in 2 attempts. She had ongoing severe PVL, hemolysis, need for multiple blood transfusions and recurrent hospitalizations for CHF before transfer to our center.
Methods Results Conclusions
Right CFA was preclosed and 16 Fr Cook sheath advanced. Using 6 Fr multipurpose guide in a 10 Fr long introducer sheath and a 10 mm Gooseneck snare, 2 of the 3 Amplatzer vascular plugs were successfully extracted. The proximal thread insert of the 3rd plug was canted into aortic wall hence it was left in situ. A 26mm S3 valve was deployed carefully within the 21mm Magna Ease valve in a standard fashion taking extra care to completely externalize the plug outside the TAVR valve. A 26mm non-compliant True balloon was then used to intentionally fracture the bioprosthetic valve at 20 atmospheres.
Diastolic BP increased from 32mmHg to 74mmHg immediately with resurgence of dicrotic notch. There was complete elimination of paravalvular gap and leak with no gradient across the aortic valve, good TAVR valve competence and no interference from the externalized plug. The patient did well after implantation and was discharged on day 4 after a prolonged hospitalization course.
Aortic paravalvular Amplatzer plug extractions and valve in valve intentional bioprosthetic valve fracture to eliminate large paravalvular gap with severe leak can be achieved with proper planning. A paravalvular Amplatzer plug may be safely left in situ and externalized outside a TAVR valve. Such procedures may change the way we think and approach paravalvular leaks in the future.