Bioprosthetic Valve Stenosis Research Articles

Early Structural Valve Deterioration of Balloon Expandable Transcatheter Aortic Valve Leaflets Due to Intrinsic and Extrinsic Nodular Calcification in a Hemodialysis Patient: A Case Report

Abstract Background Several reports have shown that transcatheter aortic valves are comparable in durability to surgical aortic valves. However, early structural valve deterioration (SVD) is rarely reported to occur, especially in hemodialysis patients. Case Summary We present a case of rapidly progressive bioprosthetic aortic valve stenosis in a patient with end-stage renal disease (ESRD) secondary to diabetic nephropathy in an 83-year-old female admitted due to progressive dyspnea and orthopnea. A 23-mm sized SAPIEN3 bioprosthetic aortic valve showed normal function for the first year after transcatheter aortic valve implantation (TAVI), but then rapidly developed stenosis and required acute hospitalization for heart failure a year and a half after surgery. Emergent surgical aortic valve replacement (SAVR) with a 19-mm On-X valve (CryoLife, Kennesaw, GA, USA) was performed. Pathological examination of the explanted SAPIEN 3 valve demonstrated severely degenerated bioprosthetic pericardial leaflets with severe intrinsic and extrinsic nodular calcification, which could limit the leaflet motion. Discussion There is a lack of reports on the long-term procedural outcomes of TAVI in hemodialysis patients. The development of SVD in patients undergoing dialysis is multifactorial and has yet to be fully elucidated. In the presented case, the removed TAVI valve had severe extrinsic calcified nodules alongside a fibrin thrombus. Considering these pathological findings, antithrombotic therapy to prevent fibrin thrombus from adhering to the TAVI valve may be important to avoid early SVD.

#1397 Predictive factors for bioprosthetic valve stenosis and prognostic factors for survival following TAVR in hemodialysis patients with severe AS

Abstract Background and Aims Transcatheter aortic valve replacement (TAVR) is a promising option for the treatment of severe aortic valve stenosis (AS) in patients undergoing hemodialysis. Although the incidence of bioprosthetic valve deterioration (SVD) after TAVR has been reported to be lower than after surgical aortic valve replacement (SAVR), hemodialysis itself is still associated with a high risk of SVD. Until now, the factors that determine the prognosis of TAVR in hemodialysis patients were unknown. We previously reported that preoperative hypomagnesemia was correlated with an increase in postoperative mean aortic valve pressure gradient (MPG), an index of bioprosthetic valve stenosis as one of the indicators of SVD, in hemodialysis patients (Ren Fail. 2022 Dec;44(1):1083-1089). However, the study had a limited sample size of 24 cases, which raised concerns about statistical power. Therefore, we re-evaluate predictors of SVD and life expectancy in a larger number of post-TAVR hemodialysis patients. Methods From April 2012 to November 2021, all 100 hemodialysis patients treated with TAVR at Osaka University Hospital were included in the analysis. Pre- and post-operative demographic and laboratory data were analyzed by linear mixed-effects model and cox proportional hazards model. Results During the follow-up period (maximum 7 years), 4 out of 100 patients required re-TAVR (valve-in-valve) due to valve stenosis. The MPG increased over time with the lower preoperative serum Mg concentration (linear mixed-effects mode; +1.40 mmHg/year per 1mg/dl lower in Mg, p=0.006). However, serum calcium, phosphate, and intact PTH levels had no significant effect on the increase in MPG. In addition, a higher preoperative left ventricular ejection fraction (LVEF) was associated with a lower risk of death in a multivariate Cox proportional hazards model (hazard ratio [HR] 0.97 per 1% increase in LVEF; P=0.02). Conclusions Consistent with our previous report, preoperative hypomagnesemia was associated with increased MPG after TAVR. In addition, preoperative low cardiac function (LVEF<40%) may be a risk factor for postoperative mortality in dialysis patients. This was a single-center observational study, and the number of patients was still small, so our data may not be necessarily applicable to every patient. Further research is needed to identify a prognostic predictor of SVD and mortality, that will lead to the prevention of adverse outcomes in hemodialysis patients.

Left atrial Thrombus formation after discontinuation of anticoagulation in patient with severe bioprosthetic mitral stenosis

BackgroundMitral valve stenosis can be a highly symptomatic condition with significant complications if left untreated. In such cases, mitral valve replacement with a bioprosthetic or mechanical valve may be a viable solution to prevent progressive disease. Current guidelines do not recommend continued anticoagulation beyond 6 months for patients who have undergone bioprosthetic valve replacement without a separate indication for anticoagulation. With this case discussion we aim to 1) Review the current indications for anticoagulation for bioprosthetic mitral valves in patients without atrial fibrillation and 2) Discuss the constellation of comorbidities that may affect the decision to begin anticoagulation therapy.Case presentationWe present a case describing a 55-year-old male with end-stage renal disease, coronary artery disease with coronary artery bypass graft surgery, and bioprosthetic mitral valve replacement 2 years prior with rapid degeneration of the replaced valve and on warfarin without a clear indication for anticoagulation. The patient was admitted for symptomatic, severe mitral stenosis and consideration of transcatheter mitral valve-in-valve replacement. During hospital admission, warfarin was discontinued and replaced with prophylactic anticoagulation. However, 8 days after warfarin cessation an intraoperative transesophageal echocardiography revealed a newly developed large left atrial thrombus leading to cancellation of the planned operation.ConclusionsThis patient developed a left atrial thrombus after discontinuing warfarin in the setting of rapidly deteriorating bioprosthetic valve stenosis and vascular comorbidities. The decision to discontinue warfarin was made in concordance with current guidelines, which do not indicate systemic anticoagulation post 3–6 months after bioprosthetic valve replacement without separate indication for anticoagulation. This case identifies the need to investigate rebound hypercoagulability and further risk stratify comorbidities which may independently increase the risk of clot formation in the setting of severe mitral valve stenosis.

Abstract 14286: Rapid Involution of a Bioprosthetic Transcatheter Aortic Valve Replacement Presenting as Late Bioprosthetic Stenosis

A 65 year old male with a bioprosthetic 29 mm Edwards Sapien Ultra S3 TAVR implant for symptomatic severe aortic stenosis presented for evaluation after a 30-day transthoracic echocardiogram demonstrated bioprosthetic valve stenosis. Following TAVR deployment, TEE showed normal bioprosthetic valve function without evidence of significant paravalvular regurgitation. There were no procedural complications. Echocardiogram performed 1-day post-implantation demonstrated expected transvalvular gradients and valve area. The patient reported immediate symptomatic improvement following TAVR. At 30 days post-implant, TTE demonstrated a peak velocity of 3.37 m/s, mean gradient of 29 mmHg, dimensionless index of 0.29, and effective valve orifice area of 0.9 cm2. This was associated with a progressive decline in exercise capacity. At 57 days post-implant, TEE showed tissue growth of the aortic root anterior to the valve stent, causing deformation and under-expansion of the valve architecture from a circular to an ovoid shape. Notably, the bioprosthetic leaflets did not appear thickened or calcified, but exhibited restricted motion as a result of the abnormal valve architecture. Peak velocity had further increased to 4.6 m/s, with a mean gradient of 57 mmHg, dimensionless index of 0.21, and calculated effective orifice area of 0.52 cm2. Bioprosthetic aortic valve valve stenosis is an expected complication of valve replacement, though typically characterized by progressive leaflet calcification and pannus formation over several years or by valve thrombosis. Here, we present a rare case of rapidly progressive bioprosthetic TAVR stenosis identified at 30 days post-implantation after normal morphology and gradients on immediate and 1-day imaging. Stenosis was characterized by a process of tissue growth anterior to the stent with involution and underexpansion of the stent architecture and morphologically normal leaflet tissue.

Abstract 18974: Transcatheter Tricuspid Valve Replacement in a Symptomatic Bioprosthetic Tricuspid Stenosis Patient With Carcinoid Heart Disease: A Case Report

Background: Patients with carcinoid heart disease are prone to the development of mild to severe tricuspid regurgitation with or without accompanying tricuspid stenosis. We present an interesting case of a patient with bioprosthetic tricuspid valve stenosis secondary to carcinoid heart disease undergoing transcatheter tricuspid valve replacement (TTVR). Case history: The patient is a 64-year-old female with metastatic carcinoid syndrome and subsequent tricuspid valve replacement with 25 mm Magna ease bovine pericardial valve. The surgery was complicated by carcinoid crisis, pneumothorax, and complete heart block. She presented with worsening shortness of breath with exertion. Echocardiography revealed severe tricuspid stenosis associated with a severely dilated right atrium, moderate pulmonary stenosis. Transesophageal echocardiography confirmed carcinoid degeneration of the bioprosthetic tricuspid valve. CT chest and abdomen with contrast showed consistent findings of severe tricuspid stenosis, metastatic carcinoid tumor with new foci in liver, lungs. Ischemic evaluation with angiography revealed normal coronaries. Decision making: The patient was evaluated by the heart team and was considered to be a prohibitive risk patient for redo surgery. We then evaluated her suitability for transcatheter valve replacement, and the patient was felt suitable for undergoing valve-in-valve transcatheter tricuspid valve replacement via the right internal jugular vein approach because of the coaxial alignment of the valve through this route. The patient successfully underwent this procedure with a 26 mm balloon-expandable valve without any complications and is currently in NYHA class I functional status. Conclusion: Carcinoid syndrome can affect bioprosthetic tricuspid valves and transcatheter valve replacement may be advantageous in replacing the affected bioprosthetic valves by reducing morbidity and mortality.

Abstract 16826: A Rare Case of an Emergent Third Valve in Valve Intervention

Introduction: Bioprosthetic valves are prone to structural degeneration due to an average lifetime of 10-15 years. Valve in Valve (VIV) TAVR has become an alternative to the high-risk surgical patients as the growing number of successful bioprosthetic valve placements and the deteriorations over time. Emergent VIV intervention effectiveness with prior multiple artificial valves is less studied. Hypothesis: We report a case of a 54-year-old male presenting with obstructive shock with history of substance abuse and bicuspid aortic valve status post bioprosthetic aortic valve with aortic root repair at age of 15(1983), aortic stenosis requiring repeat surgical bioprosthetic Aortic Valve Replacement (SAVR) (25 mm) at age 42(2011). Recalcitrant cardiogenic shock despite vasopressor. Emergent Heart catheterization showed mild coronary artery disease (CAD) and severe cardiomyopathy, Left Ventricle ejection Fraction 15-20%. Aortic valve Gradient was 80 mmHg. Transesophageal Echocardiography (TEE) ruled out endocarditis. Impella CP and Swan-Ganz catheter were placed for hemodynamic support and monitoring. Methods: The Heart Team approach was followed. Patient was at high risk of mortality and operative complications with redo sternotomy. He subsequently underwent valve in valve TAVR with self-expanding 26 mm valve. Prior surgical valve did not require fracturing post implantation. Results: Post Trans Aortic Valve Replacement (TAVR) the mean gradient on echocardiogram decreased to 10 mmHg and LVEF recovered to 55-60%. The patient was successfully weaned off Vaso-pressors and eventually discharged home. Conclusion: Most common cause of transcatheter bioprosthetic valve failure is stenosis from calcification and thrombosis. VIV TAVR in recent studies has proven to be safe with favorable outcomes. Our patient had already undergone two surgical valve interventions, presented with critical bioprosthetic valve stenosis requiring salvage TAVR for cardiogenic shock. After the Heart team approach, TAVR was opted as a more favorable option for the patient. Although, the life of a bioprosthetic valve results in multiple interventions but overall valve in Valve technique has been proven to provide expected results in emergent high-risk patients.

Heyde-like syndrome occurring for the first time following aortic valve replacement with a bioprosthesis: a case report

BackgroundHeyde’s syndrome is known as a combination of gastrointestinal (GI) bleeding and aortic valve stenosis. However, there are no reports of an association between GI bleeding and bioprosthetic valve stenosis initially occurred after aortic valve replacement (AVR), even though there are several reports that GI bleeding due to native aortic valve stenosis disappeared after AVR, and GI bleeding recurred due to bioprosthetic valve stenosis or patient-prosthesis mismatch.Case presentationAn 80-year-old woman who was on hemodialysis for 13 years had undergone AVR with a bioprosthetic valve for aortic regurgitation 3 years prior. She was admitted with acute heart failure and anemia that required repeated blood transfusions. Capsule endoscopy revealed multiple active hemorrhages of the small intestine due to angiodysplasia. Echocardiography showed severe bioprosthetic valve stenosis in the aortic valve position as a result of structural valve deterioration (SVD). Because Heyde’s syndrome was strongly suspected even though gel electrophoresis analysis of von Willebrand factor multimers, the gold standard examination for the definitive diagnosis of Heyde’s syndrome, was not performed, a redo AVR with a new bioprosthetic valve was performed. After the second AVR, both the heart failure and anemia due to GI bleeding promptly improved.ConclusionsBioprosthetic valve stenosis due to SVD can bring GI bleeding just as in native aortic valve stenosis. Redo AVR is a promising treatment if the combination of GI bleeding and valve stenosis in the aortic valve position appears even after AVR.

Percutaneous balloon valvuloplasty in a pregnant patient with pulmonary bioprosthetic valve stenosis

Percutaneous balloon valvuloplasty in a pregnant patient with pulmonary bioprosthetic valve stenosis

BIOPROSTHETIC AORTIC VALVE FAILURE IN END-STAGE RENAL DISEASE AND REINTERVENTION

BIOPROSTHETIC AORTIC VALVE FAILURE IN END-STAGE RENAL DISEASE AND REINTERVENTION

CASE REPORT: BIOPROSTHETIC VALVE ENDOCARDITIS CAUSING NON-ST-ELEVATION MYOCARDIAL INFARCTION

CASE REPORT: BIOPROSTHETIC VALVE ENDOCARDITIS CAUSING NON-ST-ELEVATION MYOCARDIAL INFARCTION

Bioprosthetic tricuspid valve stenosis in a case of rheumatic mitral valve stenosis and tricuspid valve replacement

Very little is known about the occurrence of bioprosthetic tricuspid valve stenosis in the Indian population that usually occurs within 8–10 years following tricuspid valve replacement (TVR) with a bioprosthetic valve. Here, we present a case of a 43-year-old woman suffering from chronic rheumatic heart disease who underwent prior two open mitral valvotomies and a TVR, now presented with severe mitral regurgitation and severe bioprosthetic tricuspid valve stenosis.

A valve-in-valve approach to manage severe bioprosthetic tricuspid valve stenosis.

A valve-in-valve approach to manage severe bioprosthetic tricuspid valve stenosis.

Bloody tricuspid stenosis: case report of an uncommon cause of haemoptysis.

BackgroundHaemoptysis is usually caused by pulmonary and infectious diseases. In few cases, it has a cardiac cause, such as pulmonary embolism or mitral valve stenosis. Haemoptysis may be an uncommon symptom of prosthetic valve dysfunction, being related to elevated right heart pressures.Case summaryA 22-year-old woman from sub-Saharan Africa known for a triple valve replacement was hospitalized for dyspnoea and haemoptysis. A careful clinical evaluation excluded the most common causes of haemoptysis. Transthoracic echocardiogram showed normal biventricular function, normally functioning mechanical prosthetic aortic and mitral valves, and the biological tricuspid prosthesis showed an increased transvalvular gradient. Contrast chest computed tomography scan excluded pulmonary embolism and mechanical valve obstruction, but revealed marked systemic venous hypertension. Right heart catheterization confirmed increased right heart pressures and severe bioprosthetic tricuspid valve stenosis. The patient underwent a successful percutaneous tricuspid valve-in-valve replacement, with complete resolution of symptoms.DiscussionThe increase in venous pressures due to bioprosthetic tricuspid stenosis caused veno-venous shunts: blood from the lower body was drained into the superior vena cava via the azygos vein. Increased pressure in the latter affected pressure in bronchial veins and arteries, leading to haemoptysis. Cardiac surgical reinterventions are associated with worse outcomes and higher mortality rates. Management of a degenerated prosthetic tricuspid valve is challenging and requires a multidisciplinary assessment. Transcatheter tricuspid valve replacement is becoming a feasible option in patients with prosthetic dysfunction. Based on evidence to date, tricuspid valve-in-valve replacement appears to be a safe, feasible, and effective alternative in selected young patients.

Valve-in-valve transcatheter aortic valve replacement on a self-expandable nitinol frame due to degeneration of primary bioprosthetic valve cusps. Clinical case of a high-risk surgical female patient

Introduction. We present the clinical observation of a 72-year-old female patient with high surgical risk and structural degeneration of a bioprosthetic aortic valve (AV) cusps in the form of stenosis, accompanied by severe dysfunction. Transcatheter implantation of bioprosthesis Medtronic CoreValve™ Evolut™ R-23 was performed using the valve-in-valve technique. The choice of minimally invasive treatment tactics is substantiated, a preoperative examination algorithm and a specific bioprosthesis model for such intervention are provided. Materials and methods. Imaging – echocardiography (Echo), electrocardiography, multispiral computed tomography, coronary angiography. Bioprosthetic valve calcification and stenosis with critical parameters of the bioprosthetic AV peak pressure gradient according to Echo data were the indications for minimally invasive surgery. Results. Dynamic observation revealed a progressive deterioration in the function of the previously implanted bioprosthetic heart valve in the aortic position, and a critical deterioration in the patient’s condition. After additional examination of the patient and selection of a new prosthesis, valve-in-valve transcatheter aortic valve replacement was done. The positive dynamics of the general state of the patient was noted in the early postoperative period. Echo data showed that the bioprosthetic AV peak systolic pressure gradient decreased from 90 to 29 mmHg, average gradient – from 42 to 19 mmHg. Conclusion. The minimally invasive valve-in-valve transcatheter aortic valve replacement used to correct the dysfunction of a bioprosthetic AV that was previously implanted during an open surgery was shown to be safe and effective and can be considered as one of the options for repeat valve replacement.

Invasive Hemodynamic Characteristics in Patients Undergoing Transcatheter Tricuspid Valve-In-Valve Implantation for Treatment of Tricuspid Stenosis.

We sought to describe invasive hemodynamic measurements in patients with tricuspid stenosis (TS) undergoing transcatheter tricuspid valve-in-valve (TVIV) implantation immediately pre- and postimplantation. Development of TS in patients who have undergone surgical tricuspid valve replacement with a bioprosthetic valve is a serious complication that leads to elevated right atrial (RA) pressures and decreased cardiac output. Transcatheter TVIV implantation is a viable alternative to surgical tricuspid valve replacement, but data on the hemodynamic consequences of TVIV for the treatment of severe TS are currently limited to echocardiographic assessment of Doppler-derived gradients. Eleven patients undergoing transcatheter TVIV implantation with moderate to severe bioprosthetic valve stenosis were selected for retrospective review. Right atrial mean pressure, right ventricular (RV) systolic and end-diastolic pressure, mean diastolic RA-RV pressure gradient, pulmonary artery capillary wedge pressure, pulmonary artery systolic, end-diastolic and mean pressures, and pulmonary artery pulsatility index (PAPi) both before and after transcatheter valve placement were collected from catheterization reports. After transcatheter TVIV implantation, the mean TS gradient decreased significantly (P < .01), while the mean RV end-diastolic pressure increased (P = .046). Pulmonary artery pulsatility index also increased as the TS was relieved (P = .039). Tricuspid valve-in-valve implantation results in immediate relief of TS, leading to increased RV preload with resultant augmentation of RV and pulmonary pressures. Increased PAPi following the procedure demonstrates acute improvement in RV output but remains low due to the failure of the RA pressure to decline significantly immediately following intervention.

Intentional bioprosthetic tricuspid valve fracture to facilitate transcatheter valve‐in‐valve deployment

While transcatheter valve-in-valve (ViV) implantation may reduce the number of lifetime surgical reinterventions in some patients with congenital heart disease, in other patients the bioprosthetic valve ring can lead to patient-prosthesis mismatch due to reduction of internal diameter if a transcatheter valve is implanted. A 49-year-old woman with multiple prior cardiac surgeries presented with heart failure due to bioprosthetic tricuspid valve stenosis. Initial predilation valvuloplasty suggested conventional ViV implant would produce patient-prosthesis mismatch, therefore, we intentionally fractured the bioprosthetic valve ring to facilitate optimal hemodynamics with implantation of a 29 mm transcatheter valve.

Bioprosthetic tricuspid valve stenosis: a case series

BackgroundBioprosthetic tricuspid valve stenosis is a late sequela of tricuspid valve replacement (TVR); however, detailed information regarding its clinical picture is lacking.Case summaryThirty-one patients with bioprosthetic TVR (mean age: 60.5 ± 16.6 years, male/female: 11/20) were followed-up for 79.5 ± 49.1 months (14–188 months). Eleven patients developed bioprosthetic tricuspid valve stenosis (mean tricuspid gradient >5 mmHg) at a median interval of 96 months (interquartile range: 61–114 months). The mean tricuspid gradient at the time of tricuspid valve stenosis diagnosis was 10.9 ± 3.9 mmHg. Although the mid-term tricuspid valve stenosis-free survival was favourable (92.4% at 60 and 78.7% at 84 months), it had declined steeply to 31.5% by 120 months. Ten out of 11 tricuspid valve stenosis patients showed signs of right heart failure (RHF) as manifested by oedema and elevated jugular venous pressure, requiring moderate-to-high doses of diuretics. Diastolic rumble was audible in 10 patients. Five of the 11 tricuspid valve stenosis patients required redo TVR as a result of refractory RHF. Examination of the five excised bioprostheses showed pannus in four, fusion of the commissure in three, native valve attachment in two, and sclerosis in one. Detailed clinical pictures and pathology of the explanted valves in three cases that underwent surgery are presented in this case series.DiscussionBioprosthetic tricuspid valve stenosis is not uncommon after 8 years. Tricuspid valve replacement performed at the second surgery was associated with a higher incidence of bioprosthetic tricuspid valve stenosis.

Bioprosthetic aortic valve leaflet disruption with high energy electrocautery to prevent coronary artery obstruction during valve‐in‐valve transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is well-established for the treatment of bioprosthetic aortic valve stenosis (AS) in high surgical risk patients. Coronary artery obstruction from displacement of the bioprosthetic valve leaflets during valve-in-valve (VIV) TAVR is a rare, but potentially fatal, complication. Recently, the bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure was developed as a method for disrupting bioprosthetic leaflets in patients undergoing VIV TAVR at high risk for coronary obstruction. This case describes a successful VIV TAVR utilizing a simplified concept of the BASILICA technique in a patient where the full procedure could not be completed.

P1597Incidence, clinical pictures and risk factors for bioprosthetic tricuspid valve stenosis

P1597Incidence, clinical pictures and risk factors for bioprosthetic tricuspid valve stenosis

Transcatheter Aortic Valve-in-Valve Procedure in Patients with Bioprosthetic Structural Valve Deterioration.

Surgical aortic valve replacement is the gold standard procedure to treat patients with severe, symptomatic aortic valve stenosis or insufficiency. Bioprosthetic valves are used for surgical aortic valve replacement with a much greater prevalence than mechanical valves. However, bioprosthetic valves may fail over time because of structural valve deterioration; this often requires intervention due to severe bioprosthetic valve stenosis or regurgitation or a combination of both. In select patients, transcatheter aortic valve replacement is an alternative to surgical aortic valve replacement. Transcatheter valve-in-valve (ViV) replacement is performed by implanting a transcatheter heart valve within a failing bioprosthetic valve. The transcatheter ViV operation is a less invasive procedure compared with reoperative surgical aortic valve replacement, but it has been associated with specific complications and requires extensive preoperative work-up and planning by the heart team. Data from experimental studies and analyses of results from clinical procedures have led to strategies to improve outcomes of these procedures. The type, size, and implant position of the transcatheter valve can be optimized for individual patients with knowledge of detailed dimensions of the surgical valve and radiographic and echocardiographic measurements of the patient's anatomy. Understanding the complexities of the ViV procedure can lead surgeons to make choices during the original surgical valve implantation that can make a future ViV operation more technically feasible years before it is required.