Author + information
- Received February 24, 2016
- Revision received April 15, 2016
- Accepted April 21, 2016
- Published online July 25, 2016.
- Etienne L. Couture, MDa,
- Benoit M. Labbé, MDb,
- Robert DeLarochellière, MDb,
- Josep Rodés-Cabau, MDb and
- Jean-Michel Paradis, MDb,∗ ()
- aCentre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
- bQuebec Heart and Lung Institute, Quebec City, Quebec, Canada
- ↵∗Reprint requests and correspondence:
Dr. Jean-Michel Paradis, Quebec Heart and Lung Institute, 2725 chemin Sainte-Foy, Quebec City, Quebec G1V 4G5, Canada.
A 85-year-old man was admitted due to severe symptomatic aortic stenosis. Echocardiogram demonstrated a normal left ventricular ejection fraction, an aortic valve area of 0.5 cm2, and a left ventricular outflow tract of 19 mm. Computed tomography scan showed a porcelain aorta with an aortic annulus area of 430 mm2, perimeter of 78.2 mm, and calcium score of 3132. The patient was deemed inoperable and enrolled in SAPIEN-3 (Safety and Performance Study of the Edwards SAPIEN 3 Transcatheter Heart Valve).
Based on manufacturer’s sizing guidelines, aortic annulus area measured at the cusps level on computed tomography scan corresponded between a 23 and 26 mm SAPIEN-3 transcatheter heart valve (THV) (Edwards Lifesciences, Irvine, California). Considering the high calcium score, the skirt designed to minimize paravalvular leak (PVL), and the absence of dye leak around the 23 mm balloon during the pre-implantation valvuloplasty, the heart team elected to implant a 23 mm THV. After deployment, there was moderate PVL (Figures 1A and 1B, Online Videos 1 and 2) and post-dilation (with an extra 1.5 ml) was performed. Immediately after, a rapidly worsening hypotension occurred necessitating cardiopulmonary resuscitation. Transesophageal echocardiography and aortography (Figures 2A and 2B, Online Videos 3 and 4) revealed severe intravalvular aortic regurgitation caused by a stuck leaflet. Emergent valve in valve with another 23 mm SAPIEN-3 THV was performed (Figure 2C, Online Video 5). Afterward, the hemodynamic parameters rapidly improved. Transesophageal echocardiography revealed complete resolution of the intravalvular aortic regurgitation with only a mild PVL (Figure 2D, Online Video 6). Patient was extubated the same day without neurological deficits and discharged home on day 6.
This is the first report of a stuck leaflet with a SAPIEN-3 THV (1,2). Nevertheless, its mechanism is unclear. Because the SAPIEN-3 THV features semiclosed leaflets, and as the complication occurred immediately following post-dilation, the hypothesis that one leaflet was damaged by some overdilation is attractive. It is also possible that broken calcifications in the aortic annulus might have caused anchoring of one of the leaflets through the THV stent. Finally, the position of the first THV was not too low and there was no obvious overhanging leaflet. Therefore, even with the newer generations of transcatheter valves, careful assessment of leaflet function is still mandatory after deployment, specially if post-dilation has been performed.
For supplemental videos, please see the online version of this article.
Dr. Rodés-Cabau has received research grant support from Edwards Lifesciences. Dr. Paradis has received research grant support from St. Jude Medical. All other authors have confirmed that they have no relationships relevant to the contents of this paper to disclose.
- Received February 24, 2016.
- Revision received April 15, 2016.
- Accepted April 21, 2016.
- American College of Cardiology Foundation
- Al-Attar N.,
- Himbert D.,
- Vahanian A.,
- Nataf P.