Author + information
- Received November 2, 2016
- Accepted November 17, 2016
- Published online February 20, 2017.
- Gagan D. Singh, MD∗ (, )
- Jeffrey A. Southard, MD,
- Thomas W. Smith, MD,
- Walter D. Boyd, MD,
- Garrett B. Wong, MD,
- Paul A. Perry, MD and
- Reginald I. Low, MD
- Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California
- ↵∗Address for correspondence:
Dr. Gagan D. Singh, Division of Cardiovascular Medicine, University of California Davis Medical Center, 4860 Y Street, Suite 2820, Sacramento, California 95817.
An 85-year-old male (Society of Thoracic Surgeons score 4%) was referred for transcatheter aortic valve replacement for severe aortic valve stenosis (mean gradient, 43 mm Hg). Noninvasive computed tomography sizing demonstrated annular dimensions of 32.0 × 22.6 mm, and an area of 5.65 cm2. Transcatheter aortic valve replacement with a 29-mm Edwards SAPIEN S3 valve (Edwards Lifesciences, Irvine, California) under conscious sedation was chosen.
Post balloon aortic valvuloplasty, the central aortic pressure was 110/64 mm Hg. After alignment and deployment of a 29-mm SAPIEN S3 valve (Online Video 1), the central aortic pressure was 90/40 mm Hg. The S3 delivery system was removed and a pigtail was advanced across the transcatheter aortic valve replacement valve (easily and without resistance) into the left ventricle yielding a left ventricular end-diastolic pressure of 42 mm Hg (Online Video 2). Standby transthoracic echocardiography and aortography demonstrated severe intravalvular aortic insufficiency (Figures 1A and 1B, Online Video 3). Attempts at knocking the “stuck” leaflets with a pigtail catheter were unsuccessful. An additional 29-mm SAPIEN S3 valve was delivered across the valve for successful valve-in-valve deployment (Figure 1C, Online Video 4). The central aortic pressure immediately increased to 135/66 mm Hg with repeat transthoracic echocardiography and aortography now demonstrating resolution of intravalvular aortic insufficiency (Figure 1D, Online Video 5).
SAPIEN S3 leaflet malfunction is rare overall and, to our knowledge, has been reported only after a valve-in-valve case and after post-dilation for paravalvular leak (1). Herein we describe the first report of complete SAPIEN S3 leaflet malfunction after initial deployment. The mechanism of leaflet malfunction post-deployment is unclear, with 1 proposed hypothesis suggesting that S3-containing valves have semiclosed leaflets and native aortic calcification or overhanging native leaflets may cause 1 or more leaflets to become immobilized resulting in leaflet failure. Even with the newer generation valves, acute leaflet malfunction remains an important concern mandating careful assessment and emergent treatment with an additional valve as needed. Ongoing registries will need to surveil the true incidence of this entity with future studies aimed at reducing/predicting this potential catastrophic complication.
For supplemental videos and their legends, please see the online version of this article.
Dr. Southard is on the Speakers Bureau for Edwards Life Sciences. Dr. Boyd is a consultant for Direct Flow Medical and Millipede LLC. Dr. Low is a consultant for Boston Scientific and Abbott Vascular; and has received honoraria from Boston Scientific and Abbott Vascular. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 2, 2016.
- Accepted November 17, 2016.
- American College of Cardiology Foundation