PMC6501238_01
(a, b) Transthoracic echocardiography showing a bicuspid aortic valve. (c, d) Multidetector computed tomography scan revealing a large aortic valve annulus (annular area: 726.9 mm2, perimeter: 93.38 mm, long axis: 33.9 mm, and short axis: 26.2 mm) with severe aortic annular calcification.
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Aortic root assessment was completed by multidetector computed tomography (MDCT), which revealed severe aortic annular calcification, with an aortic valve calcium score of 10133 AV and a large aortic valve annulus (Figures 1(c) and 1(d)). After using the three multiplanar reformation planes, measurements were derived from the area as well as the circumference of the virtual basal ring (mean diameter: 30.4 mm, annular area: 726.9 mm2, perimeter: 93.38 mm, long axis: 33.9 mm, and short axis: 26.2 mm).
(a) Transoesophageal echocardiography showing a severe paravalvular leak after deployment of a CoreValve Evolut R 34 mm. (b) Pulsed wave Doppler in the descending aorta showing the presence of a consistent holodiastolic retrograde flow.
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After valve deployment, fluoroscopy and transoesophageal echocardiography (TEE) (Figures 2(a) and 2(b)) revealed a PVL due to (i) suboptimal valve expansion because of interference with the valvular ring by nodular calcifications and (ii) low positioning of the aortic valve prosthesis.
(a) Fluoroscopy with complete deployment of the two Amplatzer plugs. (b) A PVL was caused by the aortic prosthesis being set too low and its poor apposition against the heavily calcified commissure of the native aortic valve. A Terumo wire was pushed through the Evolut R valve's struts and then two SVD Amplatzer plugs were implanted. Due to persistent PVL after plug implantation, a further TAV-in-TAV intervention was performed. PVL: paravalvular leak; TAV: transcatheter aortic valve.
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AVPII (Figures 3(a) and 3(b)) (AGA Medical Corp., Plymouth, Minnesota), which was positioned parallel to the first one. Again, fluoroscopy and TEE did not show any significant reduction in the PVL (Supplementary 2), and the patient remained haemodynamically unstable requiring continuous inotropic therapy.
Fluoroscopy after complete deployment of the two Amplatzer plugs and the 29 mm EDWARDS Sapien 3.
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TAV-in-TAV implantation as a rescue procedure, using a second aortic prosthesis (29 mm EDWARDS Sapien 3, Edwards Lifesciences, Irvine, California). This was deployed within the first valve (Figure 4), and the final outcome was the elimination of the AS, the sealing of the PVL, and the presence of a mild residual aortic regurgitation (Figures 5(a) and 5(b), Supplementary 3).
(a) Transoesophageal echocardiography revealing the sealing of the paravalvular leak and the presence of a mild residual aortic regurgitation after the deployment of a 29 mm EDWARDS Sapien 3. (b) Pulsed wave Doppler in the descending aorta showing an antegrade flow without diastolic flow reversal.
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TAV-in-TAV implantation as a rescue procedure, using a second aortic prosthesis (29 mm EDWARDS Sapien 3, Edwards Lifesciences, Irvine, California). This was deployed within the first valve (Figure 4), and the final outcome was the elimination of the AS, the sealing of the PVL, and the presence of a mild residual aortic regurgitation (Figures 5(a) and 5(b), Supplementary 3).