Successful SAPIEN 3 Implantation for Structural Valve Deterioration of a SAPIEN XT

An 85-year-old woman implanted with a transcatheter aortic valve (TAV) using a 23-mm SAPIEN XT (Edwards Lifesciences, Irvine, CA, USA) 7 years earlier presented to hospital with congestive heart failure. Transthoracic echocardiography (TTE) revealed a mean aortic valve pressure gradient (mAVPG) of 52 mmHg, area of 0.66 cm², and moderate transvalvular regurgitation (Figure A, Supplementary Figure). Transesophageal echocardiography and computed tomography showed no evidence of vegetation or thrombus, with no frame recoil observed in the XT. We implanted a current-generation SAPIEN 3 Ultra RESILIA 23 mm (S3) under local anesthesia (Figure B). The 30-day TTE revealed excellent results, including mAVPG of 18 mmHg and area of 1.30 cm² with no regurgitation (Figure C).

Figure.

TTE shows preprocedural mAVPG of 52 mmHg, AVA of 0.66 cm², and moderate transvalvular regurgitation (A). Angiogram showing the S3 implanted within the XT (B). The 30-day TTE shows mAVPG of 18 mmHg and AVA of 1.30 cm² with no regurgitation (C). Three-dimensional reconstructions of computed tomography image (D,E) show optimal expansion of the S3 at both the outflow and inflow, but underexpansion at the commissure posts, occurring in the gap between both stent frames (gap: yellow double-headed arrow (H); commissure post of XT: red; S3: blue) (F–I). (F) Courtesy of Edwards Lifesciences. AVA, aortic valve area; mAVPG, mean aortic valve pressure gradient; S3, SAPIEN 3; TTE, transthoracic echocardiography; XT, SAPIEN XT.

As previously reported in patients with eccentric calcification of the native aortic valve,¹ underexpansion of the S3 occurred because of the overlapping commissure posts that exist on the inside of the XT and on the outside of the S3 (Figure D–I). It had a clinically insignificant effect on valve function in the short term. Although TAV-in-TAV is considered a low-risk and effective strategy for managing structural valve deterioration, few data are available on the implantation of the S3 within the XT, particularly when involving small annulus. This case suggests that it is feasible and safe, but further research is needed, especially of procedures concerning small TAV-in-TAV.

Disclosures

T.N. is a TAVI proctor for Edwards Lifesciences.

Supplementary Files

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-23-0412

Reference

• 1.   Nakajima A, Naganuma T, Yuki H, Onishi H, Amano T, Yabushita H, et al. The impact of aortic valvular calcium on transcatheter heart valve distortion. J Interv Cardiol 2021; 2021: 8829906.