The Heart Valve Society

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Unsuccessful Anchoring of Dislocated Symetis Prosthesis with CoreVavle Evolut R resulting in Conventional Aortic Valve Replacement
Elmar Kuhn, Tanja Rudolph, Navid Mader, Thorsten Wahlers.
University Hospital Cologne, Cologne, Germany.

Patient Demographics: A 83 year-old female patient presented with progressive dyspnea on exertion and syncopes on the basis of a previously diagnosed aortic valve stenosis. Further evaluation showed a significant stenosis of the right coronary artery that was treated by percutaneous coronary intervention. Echocardiographic assessment confirmed the diagnosis of severe aortic valve stenosis (dpmax 71 mmHg, vmax 4,2 m/s, AVA 0.9 cm2). EuroSCORE II was determined to 13.6%.
Relevant History: Heart team discussion resulted in a recommendation favouring transcatheter aortic valve impantation (TAVI) over conventional valve replacement based on the patientīs individual history.
Pre-Operative Plan: Preinterventional computer tomography was conducted according to the local institutional protocol showing a heavily calcified aortic valve and an aortic valve area of 330 mm2 (perimeter 65.7 mm). Distances to the left and right coronary ostia were 8.7 and 12.4 mm, respectively. Minimal vessel diameter was 6.2 mm for transfemoral access. Finally, transfemoral implantation of a Symetis Acurate neoTM Size S was planned.
Discussion of what was actually done and the challenges, deaths and complications encountered. (Unless case is still pending): Transfemoral implantation was started with balloon aortic valvuloplasty. Implantation of the Symetis Acurate neo valve was uncomplicated initially; however, the final position of the valve was too high resulting in significant paravalvular leakage. Therefore, implantation of a second valve was necessary; a CoreValve Evolut R prosthesis (26 mm) was chosen aiming to anchor the Symetis prosthesis. Despite several attemts to position the Evolut R prosthesis, the Symetis valve slid into the ascending aorta. The procedure was converted to conventional aortic valve replacement using a biological Edwards Perimount prosthesis (size 21 mm) with cardiopulmonary bypass. Despite this complicated intraoperative course, the patient recovered quickly and was discharged to the referring hospital after nine days. The choice of the second transcatheter valve in urgent valve-in-valve procedures is crucial and needs to be adapted to the specific situation. We sought to fix the dislocated Symetis prosthesis using a CoreValve Evolut R what finally resulted in conventional surgical aortic valve replacement.


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