Intravascular Hemolysis After Transcatheter Aortic Valve-in-Valve Implantation for Degenerated Stentless Bioprosthesis

A 49-year-old woman presented with New York Heart Association class III heart failure. She had been treated three times with open heart surgeries (ventricular septal defect closure and aortic valve repair at 13 years old; aortic valve replacement [AVR] with a Hancock II at 21 years old; and AVR with a 23-mm Freestyle with the modified subcoronary technique at 34 years old). Transesophageal echocardiography (TEE) showed that one of the Freestyle leaflets was nearly detached from the annulus, resulting in severe aortic regurgitation (Figure A). After heart team discussion, we deployed a 23-mm SAPIEN 3 (Edwards Lifesciences, Irvine, CA, USA) in a relatively low position to prevent coronary obstruction and cover the nearly detached leaflet. We performed post-dilation with overfilling of the delivery balloon (+2 mL) because of residual mild-to-moderate paravalvular leakage (PVL). Final angiography showed mild-to-moderate PVL (Figure B).

Figure.

(A) Preoperative transesophageal echocardiography shows one of the Freestyle leaflets nearly detached from the annulus. (B) Final aortography. (C) Hemoglobinuria after the procedure. (D–G) Supra-skirtal leakage through the uncovered part of the SAPIEN 3 above the skirt (arrow). (H) Implantation of the second SAPIEN 3 in a relatively high position compared with the first SAPIEN 3.

After the procedure, her urine changed from yellow to green-brown (Figure C), and blood tests revealed increased levels of lactate dehydrogenase and indirect bilirubin, as well as reduced hemoglobin, suggesting intravascular hemolysis. TEE and computed tomography confirmed the relatively low implantation of the SAPIEN 3 leading to supra-skirtal leakage through the uncovered cell of the SAPIEN 3, which was the likely cause of the hemolysis and hemoglobinuria (Figure D–G). Thus, 3 days later, a second valve (26-mm SAPIEN 3) was implanted into the first valve in a relatively high position compared with the first SAPIEN 3, with complete resolution of the leak (Figure H), hemoglobinuria and hemolytic anemia. This is the first report of hemolysis due to supra-skirtal leakage following transcatheter aortic valve-in-valve implantation for a failed stentless bioprosthesis.

Disclosure

S.S. is a clinical proctor for Edwards Lifesciences.