Successful Redo Surgical Replacement of a Flail Bioprosthetic Aortic Valve: A Case Report

BACKGROUND In the last 2 decades, the use of bioprosthetic valves for surgical aortic valve replacements has surged, now accounting for over 85% of all such surgeries. However, their limited durability has led to an increase in aortic valve reoperations and re-interventions. Here, we describe a unique case involving a patient with severe aortic regurgitation and cardiogenic shock, caused by a bioprosthetic aortic valve with a flail leaflet, which was replaced via a surgical approach. CASE REPORT A 58-year-old man with a history of atrial fibrillation, stent placement in the left anterior descending artery, and 2 aortic valve replacements presented to the Emergency Department with severe chest pain and shortness of breath. A chest X-ray showed significant pulmonary vascular and interstitial congestion, and cardiac catheterization displayed nonobstructive coronary artery disease. A transesophageal echocardiogram (TEE) revealed severe regurgitation in the prosthetic aortic valve, resulting in the patient being sent for emergency aortic valve replacement. An intraoperative TEE showed evidence of prosthetic valve failure with complete prolapse of the noncoronary cusp. The prosthetic aortic valve's noncoronary cusp leaflet was found flailing into the left ventricular outflow tract, while the other 2 leaflets seemed normal. The valve was replaced and a new Medtronic Avalus size 27 mm valve was seated. Postoperatively, the patient developed a complete heart block requiring placement of a permanent dual-chamber pacemaker. CONCLUSIONS Flailed leaflets in bioprosthetic aortic valves are a rare complication of aortic valve replacement. Redo surgical valve replacement is a viable treatment for bioprosthetic failure due to leaflet flail.