Bioprosthetic valve implantation is often employed for patients with symptomatic aortic stenosis. However, paravalvular regurgitation, or PVR, sometimes occurs, and when it is moderate or severe, there is an associated twofold greater mortality.
The Heart team at UF Health sees patients from across the state of Florida and Southeast with PVRs, and management must be individualized for each patient. Novel transcatheter approaches used at UF Health include self-expanding occluder devices, balloon valvuloplasty and “Valve-in-Valve,” or ViV, transcatheter aortic valve replacement, or TAVR. However, what to do for challenging patients who have multiple PVR jets has not been well-described.
Thomas M. Beaver, MD, MPH, the Grant and Shirle Herron chair and a professor and chief of the Division of Thoracic and Cardiovascular Surgery at the UF College of Medicine, and colleagues recently reported on two cases that show ViV TAVR is particularly well-suited for patients with multiple-jet PVR.
“Paravalvular leak usually occurs in one spot,” Beaver explains, “but if not, the latest-generation transcatheter valves now have cuffs on the bottom that help seal leaks. And we can deploy those a little deeper than the previous valves for even better results.”
In the two cases published, adjunctive maneuvers included the use of a self-expanding occluder device in one patient and fracturing the previous bioprosthetic valve frame to facilitate placing a larger valve in another patient. In the latter procedure, a high-pressure valvuloplasty balloon is positioned within the valve frame and inflated to fracture the surgical sewing ring. This allows further expansion of the bioprosthetic valve as well as the implanted transcatheter heart valve, which increases the opening that can be achieved after ViV TAVR.
“Rather than having to do open surgery again, we can take very frail patients — both of these patients were actually wheelchair-bound — and return them to their normal lives,” Beaver says. “They both had Class IV heart failure with severe edema in their lower extremities. Now, after just a night or two in the hospital, they’re up and around and enjoying their families.”
Multiple-jet PVR and larger crescentic PVR are usually caused by the undersizing of the previous valve. Still, any paravalvular leak following either TAVR or open surgical aortic valve replacement can be challenging, and it is best addressed by a multidisciplinary “Heart team” approach — surgeons, interventional cardiologists and cardiologists with imaging expertise. Familiarity with multiple therapeutic options is vital to a comprehensive treatment plan, because each case will have a unique set of circumstances and technical challenges.
“UF Health has institutional experience and comfort with addressing these residual leaks,” Beaver says. “We are happy to see these patients to evaluate whether transcatheter-based options could avoid open surgery. Also, patients who previously would have been inoperable now have safe options.”