Transcatheter aortic valve replacement (TAVR) has become an alternative procedure for treating aortic stenosis in patients with advanced age and comorbidities. Although patients with previous surgical mitral valve replacement (MVR) are also indicated for TAVR, there might increase the risk of malposition of device, stuck of mechanical valve leaflet, or paravalvular leakage (PVL). My objective is to review the risk of TAVR in patients with prosthetic mitral valve with some experimental study. TAVR patients with prosthetic mitral valve had similar mortality and morbidity compared with TAVR without prosthetic mitral valve. Transcatheter heart valve (THV) migration or interaction to mitral prosthetic valve was rare. Interference of THV with prosthetic valve was high when aorto-mitral angle was less than 90° and mitral prosthesis distance was less than 7 mm in my experimental study in vitro. Anatomically implanted bileaflet valve (oriented like anterior and posterior mitral valve) or anti-anatomically implanted single tilting disc valve (major orifice opening to the left ventricular outflow tract) is a risk of impingement and stuck with THV. Preoperative evaluation of aorto-mitral anatomy and prosthetic valve implantation method by multi-modalities are important.

Objective: Transcatheter aortic valve implantation (TAVI) is an effective therapeutic procedure for treating severe aortic valve stenosis (AS) in inoperable or high-risk surgical patients. Prosthesis–patient mismatch (PPM) after TAVI or surgical aortic valve replacement (SAVR) is a critical determinant for mortality and morbidity related to the procedure. TAVI could be advantageous over SAVR regarding the reduction of risks of PPM. However, few reports have focused on outcomes for SAPIEN 3 20-mm transcatheter heart valve (THV) implantation, which is associated with higher incidence of PPM than a larger size of THV. This study aimed to compare pre- and post-procedural hemodynamic and clinical data including PPM between 20-mm and 23- or 26-mm SAPIEN 3 THVs, taking into an account for the feasibility of smaller size of THV.

Methods: This retrospective single-center observational study included data from the cardiac catheter database of Aichi Medical University between April 2017 and April 2020. The study evaluated 43 consecutive patients with severe AS who successfully underwent TAVI with balloon-expandable Edwards SAPIEN 3 prosthesis. Patients were divided into two groups: patients with 20mm THV (8 patients), and 23- or 26-mm THV (35 patients). Pre- and post-procedural hemodynamic and clinical data were assessed. PPM is defined based on the indexed prosthetic valve effective orifice area (EOA) to the patient’s body surface area (BSA), and PPM is considered moderate when indexed EOA (EOAI) is between 0.65 and 0.85 cm²/m² and severe when <0.65 cm²/m². The primary endpoint was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, and hospitalization due to heart failure, and reintervention for implanted valve failure assessed for up to 39 months of follow-up.

Results: There were no significant differences in baseline characteristics and assessed hemodynamic data except for the preoperative aortic valve area, postoperative mean pressure gradient, EOAI, and incidence of moderate PPM. All procedures were successfully performed, and the 30-day mortality rate was 0%. Although moderate PPM was more frequently observed in the 20-mm THV than in the 23- or 26-mm THV patients, severe PPM was not detected in all subjects. Major adverse cardiovascular events (MACE) only occurred in 23-mm THV patients. Moderate PPM was observed in 50% of patients with 20-mm THV, which was not associated with adverse outcomes.

Conclusions: Although this result cannot be applied to long-term results, the implantation of a 20-mm THV seems to be feasible in patients with a small aortic annulus. Long-term careful clinical follow-up is necessary after 20-mm SAPIEN 3 THV implantation.

Objective: The embolization of the transcatheter heart valve (THV) is one of the complications of transcatheter aortic valve replacement (TAVR). A migrated THV in the sinus of Valsalva (SOV) needs to be withdrawn to a supra-coronary position. In this case, we successfully pulled the valve with a novel technique using a snare catheter and balloon for coronary intervention.

Case Presentation: A 90-year-old woman with critical aortic stenosis was presented with extremely small aortic valve annulus, heavily calcified left ventricular outflow tract (LVOT), and stenosis in the left anterior descending artery (LAD). Following percutaneous coronary intervention (PCI) to the LAD, a self-expandable THV was deployed. The THV was not fully expanded because of the heavy calcification of the LVOT. The THV was retracted by the nose cone, then migrated to the zero position. Post balloon dilation for the paravalvular leak (PVL) resulted in further migration into the SOV. We could not mobilize the THV by grasping the top frame of the THV. Instead, we grasped the bottom of the stent frame, and we could pull the THV to the supra-coronary position. We passed the previously used coronary balloon through the stent frame and kept pulling the THV with a dilated balloon during the second THV implantation. The second valve was successfully implanted.

Conclusion: We experienced THV embolization and difficulty in withdrawing the THV in the case with the small annulus and heavily calcified LVOT. A combination of snaring the bottom stent frame and balloon retraction technique is a useful alternative method for withdrawing the migrated THV.

Objective: Here, we report the strategy of bailout in case of transfemoral-transcatheter aortic valve implantation (TF-TAVI)-induced iliac arterial injury during TAVI.

Case Presentation: We show a case of a 79-year-old male who presented with severe symptomatic aortic stenosis. We performed TAVI from the left common femoral artery. We inserted a 14-Fr e-sheath without difficulty, and we delivered and deployed successfully a 26-mm SAPIEN3-valve (Edwards Lifesciences, Irvine, CA, USA). When the 14-Fr e-sheath was removed, the aortography showed massive extravasation from the left iliac artery. As a result, we were able to rapidly treat the iliac perforation using Viabahn endoprostheses and less invasively than a conventional stent-graft or surgical repair while obtaining good patency with the Viabahn endoprostheses.

Conclusion: We had an experience that the use of Viabahn endoprostheses is safe and effective in case of TF-TAVI-induced iliac arterial injury during TAVI, with good short- and mid-term outcomes.

Objective: To learn the management of severe aortic stenosis (AS) complicated by cardiogenic shock.

Case Presentation: The case was an 89-year-old female with a past medical history of diabetes and stroke. She presented to another hospital after a syncopal episode. While waiting for further evaluation, she suddenly became unresponsive, and the monitor showed asystole. She was immediately resuscitated, and transthoracic echocardiography showed severe AS. Therefore, she was transferred to our hospital for further management including transcatheter aortic valve implantation (TAVI). During echocardiography, the patient developed hypotension and diffuse ST-segment depression. Transthoracic echocardiography revealed severe mitral regurgitation with preserved ejection fraction. Emergent coronary angiography did not show significant stenosis, and the patient was considered to be in cardiogenic shock secondary to severe AS. Emergent TAVI was performed under intra-aortic balloon support. Post TAVI course was uneventful, and at 1-year follow-up, the patient was in stable condition. Echocardiography at 1 year showed normal prosthetic valve function and mild mitral regurgitation.

Conclusion: Favorable outcome of severe AS complicated with cardiogenic shock could be achieved with emergent TAVI and mechanical circulatory support. Further study is warranted to identify risk factors for acute decompensation of AS causing cardiogenic shock.

Objective: Trans-apical (TA)-transcatheter aortic valve replacement (TAVR) is one of the alternative approaches in cases with poor femoral or iliac access. We have previously reported that placing a wound retractor (WR) into the pericardium provides good surgical exposure in TA-TAVR. In this case, we experienced an unexpected iatrogenic coronary obstruction due to WR.

Case Presentation: An 84-year-old man presented with symptomatic severe aortic stenosis. He had a dilated left ventricle, with proximity of the apex to the chest wall. A small WR was placed in the pericardial cavity to expose the apex. We mobilized the apex by placing gauzes in the pericardial space. We delivered the balloon expandable transcatheter heart valve under rapid ventricular pacing. Severe hypotension was sustained, and echocardiography revealed hypokinesis of the anterolateral wall. After removing the gauze from the pericardial cavity, the systolic blood pressure increased slightly. We performed coronary angiography to rule out coronary obstruction, which showed obstructions in the left anterior descending artery and diagonal branch. We suspected multiple coronary embolizations; we therefore removed the WR to obtain a clearer angiogram. A repeat angiogram showed no coronary obstruction. Then, we realized that the coronary arteries were obstructed by the ring of WR and that obstruction was exacerbated by gauzes placed in the pericardial space.

Conclusion: Although placing a WR into the pericardial cavity can facilitate the procedure, careful attention should be paid to avoid coronary obstruction in patients in the proximity of the heart to the chest wall.