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Prosthetic Valve Leaflet Resection Under Direct Vision To Avoid Coronary Obstruction And Facilitate Both Viv Tavr And Tav-in-tav
Keith Allen, Adnan Chhatriwalla, John Saxon, Russell Davis, Michael Gibson, Chetan Huded, Anthony Hart.
St. Luke's Mid America Heart Institute, Kansas City, MO, USA.

OBJECTIVE: VIV TAVR is increasingly utilized for failed surgical valves and Heart Teams are beginning to see failing THV's that may require TAV-in-TAV. In some cases, coronary obstruction risk may be high and, particularly in TAV-in-TAV, risk mitigation strategies may be inadequate leaving only the option of 'no treatment' or a higher risk re-operative surgical procedure that may include aortic root/ascending aortic replacement.
METHODS: We performed a hybrid procedure (Figure 1) in six patients in which the prosthetic leaflets of the failing surgical or THV were resected under direct vision thus minimizing the risk of coronary obstruction and a THV was implanted thus avoiding complex aortic root surgery. Patients were considered high risk for coronary obstruction for TAV-in-TAV or VIV TAVR (Fig 1A). Patients underwent sternotomy and were placed on cardiopulmonary bypass (CPB); ascending aortotomy was low if a surgical/balloon expandable valve was present and 1-cm above the top of a self-expanding THV. Prosthetic leaflets were excised (Fig 1B) and balloon expandable THV's were then implanted and post dilated with an appropriately sized non-compliant balloon (Fig 1C).

RESULTS: Mean age was 79 (mean STS score 13%); 4 had failing THV's (3 self-expanding and 1 balloon expandable) and two failing aortic surgical valves. Mean CPB time was 22 min. Intraoperative TEE showed no paravalvular regurgitation with a mean transvalvular gradient of 7 mm Hg. 30-day mortality was 0% with average length of stay of 4 days. 30-day TTE demonstrated normal functioning THV's with stable gradients.
CONCLUSIONS: In patients at high risk for coronary occlusion with traditional VIV TAVR or TAV-in-TAV, surgical resection of prosthetic surgical or THV leaflets with implantation of a THV is feasible, mitigates the risk of coronary obstruction and may minimize the trauma of re-operative surgery, particularly THV explant.


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