Author + information
- Received May 23, 2013
- Accepted June 6, 2013
- Published online February 1, 2014.
- Roshan Prakash, MBBS∗ (, )
- Gareth Crouch, MBBS,
- Majo X. Joseph, MBBS,
- Jayme Bennetts, MBBS,
- Joseph B. Selvanayagam, MBBS, DPhil and
- Ajay Sinhal, MBBS, MD, DM, DNB
- Department of Cardiovascular Medicine and Cardiothoracic Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
- ↵∗Reprint requests and correspondence:
Dr. Roshan Prakash, Department of Cardiology, Flinders Medical Centre, 1 Flinders Drive, Bedford Park, 5042 Adelaide, South Australia, Australia.
- paravalvular regurgitation
- transcatheter aortic valve displacement
- transcatheter aortic valve replacement
A 74-year-old man presented to our center with acute pulmonary edema. This was in the context of a transfemoral transcatheter aortic valve replacement (TAVR) with a 26-mm Sapien XT valve (Edwards Lifesciences, Irvine, California), 63 days before. Mild paravalvular regurgitation (PVR) had been noted both immediately after the procedure and before discharge on day 3, which remained unchanged on transthoracic echocardiography (TTE) on day 20.
Transesophageal echocardiography on this occasion confirmed severe PVR with ventricular displacement of the Sapien XT valve (Figs. 1A to 1D, Online Video 1). Cardiac magnetic resonance imaging demonstrated an angulated valve to the long axis of the ascending aorta and aortic annulus (Figs. 2A and 2B, Online Video 2).
Repeat TAVR was not considered given the perceived risk of prolapsing the valve into the left ventricle and its low position relative to the aortic annulus. An open surgical valve replacement undertaken revealed ventricular migration of the valve to the point where the external curtain was located below the level of the aortic annulus (Figs. 3A and 3B, Online Video 3). The Sapien XT valve was explanted and replaced with a 25-mm Medtronic Mosaic bioprosthetic valve (Medtronic Inc., Minneapolis, Minnesota). The patient recovered after a prolonged complicated postoperative period.
Transcatheter aortic valve dislocation, albeit a rare phenomenon, has been documented both early (1) (<7 days) and late (2) (>30 days), but no incidences as delayed as this case have been reported. The mechanism of the late transcatheter aortic valve displacement resulting in severe PVR in this case was likely a combination of undersizing of the valve, the relative nonuniformity, and the paucity of annular calcification (Figs. 4A and 4B). A single imaging modality to assess the annulus was used then with 2-dimensional TEE, which may have underestimated the annular dimensions. The current practice of using complementary imaging modalities such as 2-dimensional TEE and multislice computed tomography will provide more accurate assessment of annular dimensions and degree of calcification, aiding in better valve size selection (3).
For accompanying videos and video legends, please see the online version of this article.
Dr Sinhal is a proctor for Edward Lifesciences; and is a consultant for and on the advisory board of Medtronics Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 23, 2013.
- Accepted June 6, 2013.
- 2014 American College of Cardiology Foundation