Severe Intraprosthetic Aortic Insufficiency Immediately After Implantation of an SAPIEN 3 Ultra RESILIA Valve with Spontaneous Resolution: Case Report

Abstract

Abstract Background Aortic insufficiency(AI) is often encountered in Transcatheter Aortic Valve Replacement(TAVR) but is only rarely hemodynamically significant. Even more uncommon is the occurrence of intraprosthetic AI which often leads to hemodynamic compromise requiring additional therapeutic intervention. Case Summary An 85 year old female with severe aortic stenosis underwent elective TAVR with a size 23mm SAPIEN 3 Ultra RESILIA(S3UR) valve. After implantation, the patient developed hypotension. Transthoracic as well as transesophageal echocardiogram identified significant transvalvular AI. Persistence of AI led the team to consider a TAV-in-TAV strategy. Before a second valve system could be inserted, the patient’s blood pressure improved and AI resolved spontaneously. The patient was discharged recovered with no AI on follow up imaging studies. Discussion This is the first reported case of significant intraprosthetic AI with the new S3UR in our literature search as of writing. The new S3UR valve has several improvements from previous generations designed to increase valve area and durability as well as decreasing the incidence of paravalvular and intraprosthetic leaks. A stuck leaflet was inferred as the cause of the intraprosthetic AI and the improved design with excessive expansion may have led to this. Unlike previous case reports, intraprosthetic AI resolved without further intervention likely due to the turbulence of flow releasing the stuck leaflet. Cautious observation prevented the need for a TAV-in TAV for a rare and possibly catastrophic complication.