An 89-year-old male with symptomatic severe aortic stenosis underwent transfemoral transcatheter aortic valve implantation. The pre-procedural computed tomography showed horizontal aorta along with heavy calcification of both right and non-coronary cusps (Panels A and B). We attempted to deploy a 29-mm Evolut R utilizing cusp overlap technique in the beginning, but the prosthesis tended to migrate upward before reaching the point of no recapture even with controlled pacing. After the prosthesis had been fully recaptured up to three times, we removed the system and proceeded with a second valve. Using conventional implantation technique to deploy the second valve, we achieved an implant depth of 2 mm and mild paravalvular leak (Panel C and Supplementary material online, Video S1). Unexpectedly, a 9.8-mm aortic valve debris (Panels D–F) was discovered between inflow struts and nose cone on the retrieved first valve (Supplementary material online, Video S2). We also noticed infolding of the retrieved first valve, which may be associated with multiple recaptures in the presence of significant annular calcification (Panel G). The patient was discharged uneventfully 4 days later.
This case illustrates that cusp overlap technique might not work for patients with horizontal aorta. Because the prosthesis barely descended from mid-pigtail level into left ventricle by gravity, the first implanter had to constantly apply tension on the delivery system. Inflow struts of partially unsheathed prosthesis with a gap between inflow struts and nose cone may scrape and dislocate aortic valve debris/calcium deposits both during re-advancing a partially recaptured prosthesis or during valve positioning (Panel H).
Panels A and B: Computed tomography demonstrating horizontal aorta as well as heavy calcification of both right and non-coronary cusps; Panel C and Supplementary material online, Video S1: final result showing a second valve deployed with conventional implantation technique; Panels D–E and Supplementary material online, Video S2: revealing a large aortic valve debris between inflow struts and nose cone on the retrieved first valve; Panel F: histopathology of valve tissue with calcifications; Panel G: infolding of the retrieved first valve; and Panel H: the schematic diagram illustrating aortic valve debris/calcium deposits is scraped and dislocated during valve positioning. AV, aortic valve; C, calcium deposits on aortic valve.
Supplementary material is available at European Heart Journal online.
Funding: The authors report no specific funding related to this article.
Conflict of interest: Y.-H.C. is a proctor for the Medtronic CoreValve and Evolut R. Other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Data availability: The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementary materials.
Author notes
Shih-Jung Jang, Ying-Hwa Chen contributed equally to this work.
