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Surgical aortic valve replacement after percutaneous aortic valve implantation: what have we learned?
Pierre-Yves Litzler1, Alain Cribier, Alan Zajarias
1Department of Thoracic and Cardiovascular Surgery, Rouen University Hospital Charles Nicolle, Rouen, France. pierre-yves.litzler@chu-rouen.fr
Insights
Surgical aortic valve replacement can be safely performed after initial percutaneous valve implantation, even in high-risk patients. This case highlights the importance of careful prosthesis sizing to avoid complications like aortic insufficiency.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
- Transcatheter Aortic Valve Implantation
Background:
- Severe aortic stenosis often necessitates valve replacement.
- Percutaneous valve implantation is an alternative for high-risk patients.
- Surgical intervention may be required after percutaneous procedures due to complications.
Observation:
- An 87-year-old man with severe aortic stenosis underwent percutaneous valve implantation.
- The procedure resulted in cardiogenic shock due to severe aortic insufficiency.
- Emergency surgical aortic valve replacement was performed.
Findings:
- Operative findings included commissural paravalvular leaks and malapposed leaflets.
- Surgical replacement was successful, with uneventful discharge at 30 days and 1-year follow-up.
- Overdilatation of the stent can worsen aortic insufficiency; transapical access is an alternative for difficult vascular access.
Implications:
- Percutaneous valve implantation can stabilize hemodynamics in patients with severe comorbidities.
- Surgical aortic valve replacement is feasible after percutaneous implantation, even in initially prohibitive-risk patients.
- Careful prosthesis selection and sizing are crucial to prevent complications.
Objective:
We report the first case description of surgical aortic valve replacement after percutaneous valve implantation.
Methods:
An 87-year-old man with severe aortic stenosis who was rejected for surgical intervention underwent percutaneous valve implantation through a retrograde femoral approach. The procedure was complicated by cardiogenic shock caused by severe aortic insufficiency, leading to emergency surgical aortic valve replacement.
Results:
The operative findings revealed the presence of commissural paravalvular leaks and centrally malapposed leaflets. Surgical replacement was uneventful, and the patient was discharged on day 30, despite a challenging postoperative course. His follow-up at 1 year has been uneventful. This case illustrates that overdilatation of the stent is not recommended because it might worsen central aortic insufficiency. Moreover, the transapical route should be considered when the appropriately sized prosthesis is unable to be inserted because of inappropriate vascular access. However, despite an initial "prohibitive" surgical risk, surgical aortic valvular replacement after percutaneous valve implantation could be easily performed.
Conclusion:
Percutaneous heart valve implantation, which provides a larger surface area than balloon valvotomy, can be offered to patients with cardiogenic shock and severe comorbidities to improve their hemodynamic state and reduce their surgical risk.
