Repositioning of Bioprosthetic Valve Using Snare Technique in TAVR for Severe Aortic Regurgitation
Mary Potkonjak, Rush University Medical Center, Chicago, Illinois
Mary Potkonjak, Rush University Medical Center, Chicago, Illinois
Title
Repositioning of bioprosthetic valve using snare technique in TAVR for severe aortic regurgitation
Introduction
Transcatheter aortic valve replacement (TAVR) for the treatment of severe aortic regurgitation (AR) is currently an off-label alternative for patients in whom surgical risk is prohibitive. Anchoring the valve poses a significant challenge due to the absence of a calcified aortic annulus and often concomitant aortic root dilation. This can lead to mispositioning, valve embolization and residual AR which are the primary drivers of morbidity and mortality. We present a case of TAVR for the treatment of severe AR, in a patient with prior mechanical mitral valve, complicated by residual AR due to left ventricular embolization of aortic valve; successfully repositioned using snare.
Clinical Case
A 48-year-old female with a history of SLE causing significant valvular disease (moderate bioprosthetic aortic insufficiency and mitral regurgitation s/p bioprosthetic and redo mechanical mitral valve), as well as coronary artery disease with single vessel CABG, and systolic heart failure (EF 30%) presented with acute decompensated heart failure and hepatic congestion. Echocardiogram showed moderate- severe aortic insufficiency, despite aggressive diuresis her symptoms and metabolic derangements persisted. She underwent TAVR with a 29mm Evolut pro plusCoreValve. Root aortogram and intraprocedural echocardiogram showed severe residual aortic regurgitation due to partial left ventricular valve embolization. The valve was snared and pulled into a more aortic position using gooseneck snare. Repeat angiography and echocardiography showed improved valve position with trace AI. Patient did well post procedurally and was discharged home.
Discussion
TAVR for severe AR carries a unique set of risks that are largely related to the difficulty of anchoring the new valve without annular calcification. Presence of mechanical mitral valve adds to the complexity in positioning the aortic valve as the valve can potentially embolize. Recent studies have shown reduction in complications with newer valves, while the use of self-expanding “oversize” valves can also help mitigate the risk. When the valve partially embolizes into the left ventricle, snaring the valve and pulling it into an aortic position can be safely performed, as we have demonstrated in this case.