Case 1
A 68-year-old male with ischemic cardiomyopathy, status post left
ventricular assist device (LVAD), presented with symptoms of progressive
shortness of breath and fatigue due to moderate-to-severe aortic
insufficiency. The patient was assessed and considered prohibitive risk
for aortic valve replacement by the Heart Failure Team and referred for
TAVR evaluation. A transthoracic echocardiogram was done, showing left
ventricular dysfunction with an ejection fraction of 10% and severe
aortic insufficiency concerning for closed-loop recirculation (Figure
1).
We chose a Medtronic 34 mm Evolut with the goal of properly oversizing
the native annulus. Since the valve was unable to provide a sustainable
fix to the existing insufficiency, the LVAD flow was regulated during
the procedure to avoid displacement of the bioprosthetic valve into the
left ventricle by the existing regurgitation. At that point, we decided
to place a #29 size Balloon-expandable Edwards SAPIEN 3, oversizing it
by adding an extra 4cc to the nominal valve volume and deploying it as a
VIV within the aforementioned Medtronic Evolut valve. The overexpansion
of the SAPIEN 3 Valve made it possible to anchor both valves in a
non-calcified annulus (Figure 2). Postoperatively, a transesophageal
echocardiogram showed an improved left ventricular ejection fraction of
15%, a mean pressure gradient of 2.2 mmHg, and a LVOT diameter of 2 cm.
There were no complications from the procedure and excellent hemostasis
was obtained. Patient was discharged home postoperative day 3. On
further follow up, the patient felt significantly better and was
extremely pleased with the results.