Redo-Transcatheter Aortic Valve Replacement With a 26 mm Sapien Valve in a 26 mm Evolut Valve to Correct Significant Paravalvular Leak via Transcarotid Access.

Abstract

An 84-year-old man with multiple comorbidities including severe aortic stenosis, heart failure with a reduced ejection fraction, severe peripheral artery disease with prior bilateral iliac artery stents, and trifascicular block presented for evaluation for aortic valve replacement. He was deemed high risk for surgical valve replacement. Preprocedural computed tomography angiography (CTA) for transcatheter aortic valve replacement (TAVR) planning demonstrated an annular area of 295 mm² and perimeter of 62 mm. There was significant slice misregistration on CT; thus, we performed multiple re-measurements in different phases of the cardiac cycle. The patient sized for either a 23 mm Evolut FX+ (16% oversizing) or a 26 mm Evolut FX+ (30% oversizing). The left and right coronary artery heights were 17 and 19 mm, respectively. Transfemoral access was not possible due to severely calcified stenotic lesions with a maximal diameter of 4.6 and 3.8 mm in the right and left common iliac artery, respectively. He underwent dual-chamber permanent pacemaker implantation 5 weeks before scheduled TAVR. With a multidisciplinary heart valve team, the patient underwent left transcarotid TAVR with a 26 mm Evolut FX+ valve with resultant moderate-severe paravalvular leak on transesophageal echocardiography (TEE) that did not improve despite multiple post-dilations with 22- and 24-mm balloons at the inflow of the valve. At this point, we re-evaluated the preprocedural CT, utilizing the noncardiac gated series which showed less slice misregistration. The annular area measured 504 mm² with a perimeter of 80 mm, thus sizing for a 26 mm Sapien 3 Ultra (3% oversizing). The next day, the patient underwent successful left transcarotid valve-in-valve TAVR with a 26 mm Sapien 3 Ultra valve deployed with the outflow positioned at node 6 of the Evolut valve. The valve was post-dilated with a 25 mm balloon, resulting in no paravalvular leak on TEE. This case highlights a safe and effective strategy to correct significant PVL post-TAVR with a larger 26 mm Sapien 3 Ultra valve inside a 26 mm Evolut FX+ valve.