Author + information
- Received October 17, 2014
- Revision received December 17, 2014
- Accepted January 15, 2015
- Published online May 1, 2015.
- Felipe Fuchs, MD, MSc∗,
- Vedat Tiyerili, MD∗,
- Wilhelm Roell, MD, PhD†,
- Eberhard Grube, MD, PhD∗,
- Nikos Werner, MD, PhD∗,
- Georg Nickenig, MD, PhD∗ and
- Jan-Malte Sinning, MD, PhD∗∗ ()
- ∗Department of Medicine II, Heart Center Bonn, University Hospital Bonn, Germany
- †Department of Cardiac Surgery, Heart Center Bonn, University Hospital Bonn, Germany
- ↵∗Reprint requests and correspondence:
Dr. Jan-Malte Sinning, Heart Center Bonn, Department of Medicine II, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53105 Bonn, Germany.
- transcatheter aortic valve implantation
- transcatheter aortic valve replacement
An 89-year-old female patient presented with worsening symptoms of heart failure (New York Heart Association class III). Echocardiography revealed severe aortic stenosis (valve orifice area 0.5 cm2) with severely calcified leaflets. As a result of comorbidities and advanced age, the heart team opted for transcatheter aortic valve replacement via femoral access with implantation of a fully repositionable Lotus 23-mm valve (Boston Scientific, Natick, Massachusetts). After balloon pre-dilation with a 20-mm Z-MED II balloon aortic valvuloplasty (BAV) catheter (NuMED, Hopkinton, New York), the valve was deployed in the usual fashion (Figure 1A). Despite several repositioning attempts, it was not possible to properly expand the valve because of severe calcification of the left-coronary cusp of the aortic valve (Figures 1A and 1B, Online Video 1). Simultaneous assessment of the left ventricular and aortic pressures at this point demonstrated a persistent transvalvular gradient (peak-to-peak 31 mm Hg) (Figure 1C). Although no data had been reported yet, the team decided to post-dilate the Lotus valve, considering that the residual gradient was unacceptable. This was performed with a 22-mm BAV catheter with complete resolution of the transvalvular gradient (Figure 1D), adequate expansion of the valve (Figures 1E and 1F, Online Video 2), and no complications (1).
This case highlights one of the limitations of self-expanding valves, which might not be as robust without balloon dilation during deployment as balloon-expandable valves. To our knowledge, we report the first post-dilation of a Lotus valve (2). Despite not indicated to be done routinely, it might be considered in cases with serious prosthesis frame underexpansion and significant residual gradient.
For accompanying videos, please see the online version of this article.
Dr. Grube works as a proctor for Medtronic. Drs. Werner, Nickenig, and Sinning have received research grants and speaker honoraria from Medtronic and Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 17, 2014.
- Revision received December 17, 2014.
- Accepted January 15, 2015.
- 2015 American College of Cardiology Foundation
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