Aortic Valve Trifecta

Abstract

Mr SM is an 83-year-old male with severe aortic regurgitation, congestive heart failure, hypertension, ischaemic heart disease s/p CABG in 2008, BPH, GERD, hypothyroidism and carotid artery occlusion. He had severe aortic stenosis and underwent a surgical AVR in 2013 (27 mm St Jude Trifecta valve). This valve was complicated by bioprosthetic valve degeneration for which he had a valve-in-valve TAVR (29 mm CoreValve) 1.5 years later. One year after his repeat TAVR, he developed acute onset dyspnoea and chest pain and was admitted to hospital. He had a NSTEMI (likely secondary to demand ischaemia) and was found to have severe aortic regurgitation. His blood cultures had been negative to date at the time of evaluation. Given his high surgical risk as a 3rd sternotomy and his haemodynamic instability, a repeat valve-in-valve TAVR was thought the best management option for him. This was performed urgently with a 26 mm Edwards XT valve via a right transfemoral approach. Since his procedure, he has had positive antibodies for Chlamydia pneumoniae. It is unclear if this indicates a current infection or just a previous exposure. Infectious disease recommended a repeat antibody test in 3 months time. In the meantime, he has been placed on long-term antibiotics. This case highlights the difficult dilemma of treating patients with degenerative bio-prosthetic valves and raises the question of why he had two early valve failures and what his long term monitoring and treatment plan should be.