2019 Scientific Sessions

Title: Simultaneous PVL repair and ViV TAVR for actively dehiscing bioprosthetic AVR with complete resolution of cardiogenic shock-liver-kidney-recurrent VT. Introduction: We report the first successful percutaneous rescue of an actively dehiscing bioprosthetic AVR obviating second redo AVR in a prohibitive risk patient with a rocking prosthesis and severe PVL induced multi-system organ failure and recurrent VT. We highlight the importance of ViV therapy to arrest rocking prosthesis combined with PVL repair which allowed complete resolution of multi-system organ failure and discharge to home. Clinical Case: 58 yo white male with severe Bicuspid AS underwent routine SAVR 8/17 with a 29mm Edwards Perimount. Ten months later (6/18), patient presented in CHF with discovery of severe PVL secondary to valve dehiscence. He underwent PVL repair with a 10mm VSD device with moderate residual PVL resulting in severe hemolysis requiring first redo SAVR with a 29mm Edwards Magna using heavily reinforced pledgeted sutures. Six months later (12/18), patient presented in complete heart block requiring a pacemaker. Echo at that time showed normally function prosthetic valve without PVL. One month later (1/19), the patient presented with syncope and was found to have recurrent VT as a result of rocking, unstable, actively dehiscing bioprosthesis with severe PVL resulting in cardiogenic shock-liver-kidney and hypoxic respiratory failure requiring mechanical ventilation. Live 3D TEE guided PVL repair was achieved with two intercalated AVP2 devices (12mm and 16mm) which reduced PVL from severe to mild, however, PVL repair did not arrest the valvular rocking motion. Follow-on ViV with a 34mm Medtronic CoreValve Evolut Pro to prevent further valvular dehiscence and achieve stabilization of rocking prosthesis was performed. Due to renal failure, the PVL repair/ViV procedure was performed with zero contrast and using argatroban due to prior history of heparin induced thrombocytopenia. The patient was extubated on POD#2. EF improved on POD#1 with residual mild PVL and reduction of moderate MR to trace. No recurrent VT was encountered. Shock liver-kidney resolved by POD#4. Suspecting culture negative endocarditis, patient was treated with Doxycycline, Daptomycin, and Cefepime. The patient underwent device upgrade to an ICD for secondary prevention. There was no evidence of endocarditis or paravalvular abscess during both events of valvular dehiscence leading our team to believe an underlying aortopathy as a plausible etiology for these events. Discussion: This case highlights the percutaneous option for rocking or mobile prosthesis in a prohibitive risk patient with excellent outcome. It is theorized that the rocking prosthesis confers a pseudo-mechanical outflow tract obstruction despite normal prosthetic leaflet function which resulted in multi-system organ failure. Additionally, the rocking valve caused recurrent VT with focus from LVOT/AoV region. Treating the PVL combined with arresting the rocking motion provided an enormously successful outcome with complete resolution of multi-system organ failure and recurrent VT for this prohibitive risk patient.