Title
Rescue Valve-in-Valve TAVR Following Valve Migration in an LVAD Patient
Introduction
A 63-year-old woman with end-stage heart failure supported with a durable left ventricular assist device (Abbot
HeartMate 3) and chronic right ventricular failure requiring milrinone developed severe aortic insufficiency two years after LVAD implantation. She was deemed not to be a candidate for heart transplantation and was therefore offered transcatheter aortic valve replacement (TAVR) for treatment of pure aortic insufficiency. A self-expanding valve (Medtronic
Evolut FX+) was selected. Following deployment, the prosthesis migrated into the left ventricular outflow tract (LVOT) with an associated skirt miss. A balloon-expandable valve (Edwards
Sapien 3 Ultra Resilia) was subsequently implanted within the self-expanding valve as a scaffold with an excellent result.
Clinical Case
Following LVAD implantation, the patient experienced recurrent heart failure hospitalizations. Transthoracic echocardiography initially demonstrated mild-to-moderate aortic insufficiency. Transesophageal echocardiography revealed severe, eccentric aortic insufficiency with a coaptation defect. The patient was determined to be ineligible for heart transplantation and at prohibitive surgical risk for surgical aortic valve replacement. After a multidisciplinary heart team evaluation, TAVR was offered for the treatment of pure aortic insufficiency. Pre-procedural CT demonstrated an annular perimeter of 70 mm and an annular area of 376 mm² with similar LVOT dimensions. The aortic valve calcium score was 0. A 26-mm Evolut FX+ valve was selected, providing 16.4% annular oversizing. During the procedure, LVAD speed was temporarily reduced, and the valve was deployed to 80% under rapid ventricular pacing. After release, the prosthesis migrated into the LVOT with an associated skirt miss. Given the inadequate skirt seal, a 23-mm (+2 mL) Sapien 3 Ultra Resilia valve was implanted high within the Evolut frame at approximately node 6 to create an effective seal. Final aortography demonstrated only mild (1+) central aortic insufficiency. The patient was discharged the following day. Unfortunately, five weeks later, she developed progressive right ventricular failure and ultimately elected to withdraw care.
Discussion
This case serves as an example of valve migration in the setting of pure aortic insufficiency, adequate valve oversizing, and rescue valve-in-valve TAVR for skirt miss in a patient with a durable LVAD. At the time of this case, there were no commercially available TAVR implants for pure aortic insufficiency, thus options for TAVR were off-label. These devices do not have specialized anchors as compared to investigational devices to decrease the risk of valve migration. Additionally, adequate valve oversizing is important due to the lack of aortic valve leaflet calcium to anchor the valve within the annulus. Knowledge of TAV-in-TAV is important in this case to understand the level of the self-expanding valve outflow and how the level of the balloon-expandable valve interact to create the neoskirt plane with a potentially abnormal implantation depth in order to seal the skirt miss in this scenario without putting native coronary flow at risk. This case demonstrates that a valve-in-valve implantation can be used as a rescue strategy for valve migration with associated skirt miss.