Successful percutaneous balloon aortic valvuloplasty for worsening paravalvular leakage detected one week after the balloon expandable transcatheter aortic valve replacement

概要

A 75-year-old woman with severe aortic stenosis was referred to our hospital for transcatheter aortic valve replacement (TAVR). Pre-procedural computed tomography (CT) revealed the aortic valve annulus without significant calcification (373.54 mm2) and a small sinutubular junction with severe calcification (21.9 x 23.8 mm). The 23- mm SAPIEN 3 (Edwards Lifesciences Inc., Irvine, CA, USA) was implanted relatively deep with nominal inflation volume to avoid its attachment to the calcified STJ. Immediately after the valve deployment, transesophageal echocardiography (TEE) revealed trivial paravalvular leakage (PVL). However, after the TAVR, her heart failure was gradually worsened. One week after TAVR, transthoracic echocardiography revealed PVL became severe. Post-procedural CT assessments demonstrated a gap between the stent and the interleaflet triangle between the right and left coronary aortic sinuses due to inadequate valve expansion, which suggests requiring additional balloon expansion. Thus, on day 21 after TAVR, we performed an additional percutaneous balloon aortic valvuloplasty (BAV) with 23-mm balloon, followed by significant PVL reduction from severe to mild in both angiographical and echocardiographic findings. Post-procedural CT demonstrated a sufficient valve expansion and the gap disappeared. At one-year follow-up, no cardiovascular adverse events occurred and transthoracic echocardiography showed remaining mild PVL. Delayed worsening PVL is a rare but potentially serious complication of TAVR. Generally, there are two possible mechanisms to be considered: elastic recoil and valve migration1. In the current case, inadequate seal of the TAVR prosthesis to the aortic annulus due to relatively deep valve implantation, in addition to some elastic recoil, could cause this delayed worsening PVL. In order to avoid aortic injury and deep implantation, the two-step inflation technique is considered as useful2. In brief, the TAVR prosthesis is first deployed with underfilled volume, and then post-dilation is performed with nominal or overfilled volume in the lower half of the TAVR prothesis. The catheter therapeutic options to manage PVL include BAV, transcatheter valve-in- valve implantation, and percutaneous PVL closure3. Based upon CT findings suggesting that stent under-expansion with a gap between the transcatheter heart valve and the native aortic wall, we performed additional BAV. Post-procedural CT assessments are helpful to choose the appropriate therapeutic strategy for worsening PVL. The medical course of our patient notes that PVL should be monitored closely both immediately after TAVR and during the follow-up period.

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