Abstract
Transcatheter aortic valve replacement in the setting of failed surgical bioprosthesis (valve-in-valve) is a valuable option for patients with bioprosthetic aortic stenosis or regurgitation who are deemed high risk for repeat open heart surgery. Although the procedure is successful with proper preprocedural assessment, instances of left main (LM) coronary artery ostium obstruction have been documented. We present a case of LM coronary obstruction in the immediate postoperative period following implantation of a 20-mm Edwards Sapien 3 valve inside the degenerated 21-mm Mitroflow bioprosthesis stenosis, which was treated with double stenting alongside the Edwards Sapien 3 valve creating a channel (“neo left main”) that extended from mid-LM to the upper margin of the Edwards Sapien 3 valve. Although valve-in-valve in a Mitroflow degenerated bioprosthesis is a relatively safe procedure, 2 or more stents may be necessary to scaffold a channel to the coronary arteries between Edwards Sapien 3 prosthesis and aorta in the event of a coronary obstruction.
Highlights
With the advancement in technology, transcatheter aortic valve replacement (TAVR) for failed surgical aortic bioprosthesis has become a widely accepted option for patients at high risk for redo open heart surgery.[1]
Data suggest that insertion of Edwards Sapien 3 valve in VIV procedure is not associated with coronary obstruction.[6,7,8,9,10]
We reported the first case of left main (LM) coronary ostium obstruction following insertion of Edwards Sapien 3 valve on degenerated Mitroflow aortic bioprosthesis stenosis, successfully treated with the insertion of 2 bare metal stents creating a channel between Edwards Sapien 3 valve and aorta toward LM coronary artery ostium
Summary
With the advancement in technology, transcatheter aortic valve replacement (TAVR) for failed surgical aortic bioprosthesis (valve-in-valve [VIV]) has become a widely accepted option for patients at high risk for redo open heart surgery.[1]. Past surgical history was significant for aortic valve replacement using a 21-mm Mitroflow bioprosthesis for aortic stenosis and coronary artery bypass surgery with a left internal mammary artery. Coronary angiography showed a left dominant circumflex and atretic left internal mammary artery graft to the distal left anterior descending artery. Transfemoral implantation of a 20-mm Edwards Sapien 3 valve inside 21-mm Mitroflow bioprosthesis under the guidance of transesophageal echocardiography was initially uneventful (Figure 1). Stat echocardiography showed a mild reduction in left ventricular systolic function, but no evidence of pericardial effusion, aortic root dissection, or aortic hematoma. Two bare metal stents were needed to scaffold the Edwards Sapien 3 valve efficiently and to provide a new LM coronary artery channel
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