Valve-in-Valve Transcatheter Aortic Valve Replacement With Intracardiac Echocardiography Focusing on the Membranous Septum

An 85-year-old woman presented with heart failure due to bioprosthetic dysfunction with severe intraprosthetic regurgitation. At 72 years old, she had undergone aortic valve replacement with a 23-mm Mosaic Ultra (Medtronic, Minneapolis, MN, USA) in a supra-annular position. We decided to perform a valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) utilizing a 23-mm Evolut PRO+ (Medtronic) with minimal contrast due to poor renal function. In the case of Mosaic valves, the absence of fluoroscopic markers on the sewing ring makes it difficult to identify the level of the Mosaic valve’s neo-annulus, leading to difficulty in adjusting the depth of an Evolut without contrast (Figure). AcuNav (Biosense Webster, Diamond Bar, CA, USA) intracardiac echocardiography (ICE) revealed a membranous septum length of 2.2 mm. During the first attempt, the valve was considered too shallow. During the second attempt, the ECG displayed new complete left bundle branch block, while ICE showed direct contact of the valve frame with the muscular septum. On the third attempt, the valve positioned slightly deeper, however, the ECG displayed a narrow QRS complex. ICE indicated that the valve frame was not engaging the muscular septum and was floating above the membranous septum (Supplementary Movie). The patient was discharged without conduction disturbances.

Figure.

No fluoroscopic markers on the bottom of the Mosaic valve (A). Membranous septum measuring 2.2 mm on ICE (arrowhead) (B). ICE not showing the Evolut frame (C,D). ICE showing direct contact of the Evolut frame with the muscular septum (yellow arrowheads) (E,F). ICE indicating Evolut frame not engaging the muscular septum (yellow arrow) and floating above the membranous septum (red arrow) (G,H). Postprocedural echocardiography showed no direct contact of the valve frame (arrowheads) with the anterior mitral leaflet (I,J).

This is the first report to demonstrate the effectiveness of ICE for accurately implanting a self-expanding transcatheter heart valve (THV) to avoid conduction disturbances, even with a Mosaic valve where it is difficult to fluoroscopically confirm the lower end. The relatively low incidence of permanent pacemaker implantation following ViV-TAVR might be related to the higher position of the THV and the protection given by the surgical valve ring, which buffers the THV expansion and prevents it from directly contacting the conduction system.

Supplementary Files

Supplementary Movie

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https://doi.org/10.1253/circj.CJ-23-0205