2025 Scientific Sessions

Title:
Challenging structural case

Introduction:
Valve-in-valve procedures carry increased risks of adverse hemodynamics and coronary obstruction. Ancillary techniques to address these issues, including valve fracture and leaflet modification, carry their own potential complications

Clinical Case:
68-year-old female with hypertension, hyperlipidemia , prior h/o aortic valve replacement with 21mm peri mount 2700 bioprosthetic valve in 2013, B cell lymphoproliferative disorder of left breast s/p radiation with worsening dyspnea and chest pressure for the last 8 to 10 months. She reports feeling exactly like she did prior to her valve replacement in 2013. She cannot walk to the top of the bleachers when going to watch her grandson play ice hockey. Echocardiogram shows Severely increased left ventricular wall thickness. Normal left ventricular systolic function with EF 60%. 21 mm pericardial Bioprosthetic valve with thickened and calcified leaflets. AV mean gradient is 42 mmHg. AV peak velocity is 4.2 m/s. DVI 0.27. Acceleration time 108 ms. EOA 0.8 cm2. Our pre procedure planning based on CT TAVR and STS Risk Mortality (%): 5.54 was to place Sentinel device, Leaflet modification – unicorn and implant S3 UR 23 mm Valve. Procedure was performed through right transfemoral approach with Guide : AL guide via the L CFA access. IM and a MPA catheter in mother-daughter configuration. An Astato wire was loaded in a PiggyBack converter and advanced through the traversal guide. Leaflet traversal was attempted with electrification under pure cut mode at 30W. The wire did not cross the leaflet despite multiple attempts. Balloon valvuloplasty was performed with 22mm True balloon deployed at high pressure for bioprosthetic valve modification. Unfortunately, the balloon ruptured at peak inflation - it was immediately withdrawn to the descending aorta but there was difficulty withdrawing the balloon out of the eSheath. In view of this, the balloon and eSheath were removed en bloc and a new eSheath was inserted. 23mm SAPIEN 3 Ultra RESILIA valve was successfully placed. Mean AV pressure gradient decreased from 80.99 mmHg to 2.35 mmHg after TAVR. TEE during procedure showed a perforation was noted at the aortomitral continuity at the lower edge of the valve frame. This was associated with effective severe MR and flow reversal in pulmonary veins.. Following extensive discussions with interventional cardiology, structural imaging team anesthesiology, and cardiac surgery, we decided to proceed with closure. A Versa Cross RF system was used for transeptal puncture into the LA. Agilis sheath with an angled glide catheter in was steered towards the atrial side of the perforation.A Glidewire advantage was advanced through the perforation to the LV.The glide catheter was used to introduce a shaped Amplatz extrastiff wire. The Amplatz delivery sheath was then introduced over the extrastiff wire.10mm ASO device to close the perforation. TEE showed no LVOT obstruction or device interference with the new aortic bio prosthesis. The device was well seated and stable on tug testing, so it was released.

Discussion:
Multidisciplinary team-based approach is crucial to manage these complications. Know your tools and equipment and think outside the box.