Author + information
- Received November 5, 2018
- Revision received November 26, 2018
- Accepted December 11, 2018
- Published online March 4, 2019.
- aDepartment of Interventional Cardiology, University of Rochester Medical Center, Rochester, New York
- bDepartment of Cardiac Surgery, Mercy Hospital of Buffalo, Buffalo, New York
- cDepartment of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
- ↵∗Address for correspondence:
Dr. Syed Y. Naqvi, Department of Cardiology, Strong Memorial Hospital, 601 Elmwood Avenue, Rochester, New York 14620.
A 74-year-old man with a past medical history of diabetes mellitus, hypertension, severe aortic stenosis, coronary artery disease status post-coronary artery bypass surgery with left internal mammary artery, vein graft, and aortic valve replacement with a Rapid Deployment Edwards 23-mm Intuity Elite valve (Edwards Lifesciences, Irvine, California) 6 months before. It was deployed at 4.5 atm. The intraoperative echocardiogram showed that the valve was well seated. The patient’s post-operative recovery was uncomplicated. Twelve weeks post-op, he noticed increasing fatigue, dyspnea, and fever. His blood pressure was 120/40 mm Hg, and heart rate was 90 beats/min. On physical exam, there was a harsh 2/6 decrescendo murmur heard loudest at the left sternal border. His blood cultures grew Neisseria elongata. Transthoracic echocardiogram showed a moderate-to-severe paravalvular leak. Transesophageal echocardiogram showed a severe paravalvular leak without any vegetation. The computed tomography scan showed the paravalvular leak was secondary to a poorly apposed stent skirt in the annulus (Figure 1). After discussions with the infectious disease team, the patient was empirically treated for 6 weeks for endocarditis, despite no evidence of vegetation on his valve. After treatment of his endocarditis, he had ongoing dyspnea and fatigue with minimal exertion, so he was referred to our institution for percutaneous leak closure. We decided to do a balloon valvuloplasty (BAV) of the valve skirt to more fully appose the valve skirt and seal the leak. We had a transcatheter aortic valve ready in case we fractured the stent frame or damaged the valve leaflets. BAV was performed with 22-mm followed by 26-mm True balloons (Bard Peripheral Vascular, Tempe, Arizona) with rapid pacing at 10 atm (Figure 1, Online Video 1). The patient recovered well with resolution of his symptoms. His echocardiogram during and 1 month after his procedure showed no residual paravalvular leak.
Over recent years, particularly in Europe, aortic valve replacement with a rapid-deployment valve has become a common alternative to mechanical or bioprosthetic stented valves, allowing quicker operative time and reduced aortic cross-clamp time. This valve has shown excellent hemodynamic performance and acceptable long-term safety over 5-year follow-up; however, the rates of pacemaker implantation remain high (1). In the TRANSFORM (Multicenter Experience With Rapid Deployment Edwards INTUITY Valve System for Aortic Valve Replacement) trial, the rates of pacemaker implantation, and moderate and severe paravalvular leak were 13.6%, 1.2%, and 0.4%, respectively (2,3). Sutureless valve implants should be monitored post-operatively for such complications. BAV is a feasible treatment option for patients with an inadequately apposed Intuity valve.
Dr. Prasad is a consultant for Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 5, 2018.
- Revision received November 26, 2018.
- Accepted December 11, 2018.
- 2019 American College of Cardiology Foundation
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