Author + information
- Received July 22, 2012
- Accepted August 2, 2012
- Published online March 1, 2013.
- Nicolas Dumonteil, MD⁎ (, )
- Bertrand Marcheix, MD, PhD,
- Etienne Grunenwald, MD,
- Jérôme Roncalli, MD, PhD,
- Pierre Massabuau, MD and
- Didier Carrié, MD, PhD
- ↵⁎Reprint requests and correspondence:
Dr. Nicolas Dumonteil, Service de Cardiologie B. CHU Rangueil, 1 Avenue Jean Poulhès TSA 50032, 31059 Toulouse, Cedex 9, France
An 83-year-old man with severe symptomatic aortic stenosis, deemed to be high risk for conventional surgery (Logistic EuroSCORE 26.63%, Society of Thoracic Surgeons Score 7.2%) was referred to our institution for a transcatheter aortic valve implantation. A transapical approach was chosen, because his anatomic features were not suitable for transarterial access. The aortic annulus measured by transesophageal echocardiography (TEE) was 23.8 mm (Fig. 1).
A 26-mm Edwards-Sapien (Irvine, California) valve was implanted with fluoroscopy and TEE guidance with 1-step inflation, as previously described (1). Although there were no technical problems during deployment, the prosthesis embolized into the left ventricle a few seconds after hemodynamic recovery (Fig. 2A,Online Video 1). The stiff wire was kept in place, preventing the prosthesis from rotating and obstructing the left ventricular outflow tract (Fig. 2B). Because conventional surgery had been declined for this patient, we tried to find an interventional solution.
An oversized 28-mm aortic valvuloplasty balloon was placed over the stiff wire and partially inflated during rapid pacing bursts, once its distal part was in the prosthesis. After a few attempts the prosthesis was captured. It was then pushed into the aortic annulus, and because it was possible to reposition it, it was fixed by a full 5-sec inflation in a stable, high position (Figs. 3A and 3B, Online Video 2) but with a severe paravalvular regurgitation (Fig. 3C). A second 26-mm Edwards-Sapien valve was then implanted deeper into the first one with an overlay of four-fifths to the previous prosthesis (Fig. 4A). Final TEE showed a good prosthesis function, with a mild paravalvular leak (Fig. 4B). Post-operative course was uneventful. At the 1-month follow-up, the patient was in New York Heart Association functional class II. Transthoracic echocardiography showed an effective orifice area of 1.3 cm2, a mean gradient of 12 mm Hg, and a mild paravalvular leak.
To the best of our knowledge, this is the first case that demonstrates the feasibility of recapturing a balloon-expandable prosthesis after left ventricular embolization. Among various potential causes of such a complication (2), mild valve calcifications and a possible underestimation of the true annular size by TEE are the most likely. A multimodal annulus sizing with a computed tomography scan (3) could have been helpful but was not included in our selection process at this time before balloon-expandable prosthesis implantation.
Dr. Dumonteil is a physician proctor for Edwards Lifesciences and Medtronic and a consultant for Boston Scientific and Biotronik. Dr. Marcheix is a physician proctor for Edwards Lifesciences and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 22, 2012.
- Accepted August 2, 2012.
- American College of Cardiology Foundation