First Transcatheter SAPIEN 3 Valve-in-Valve Implantation in an Early Degenerated Lotus Valve Prosthesis

Objectives: An 84-year-old female with severe aortic stenosis and dyspnea NYHA class III underwent a transcatheter aortic valve implantation with a 27 mm Lotus valve (Boston Scientific, Marlborough, MA, USA) with no residual valvular or paravalvular regurgitation (PAR). After discharge the patient was asymptomatic with freedom from dyspnea (NHYA I) and in good health condition. Three months later she felt breathless again and was readmitted to our hospital with cardiac decompensation and NYHA class IV.

Methods: Transesophageal echocardiography showed severe valvular aortic regurgitation due to functional failure of one valve cusp. No paravalvular leakage was observed. Severe aortic regurgitation was confirmed at invasive angiography. In view of her advanced age and risk profile, a valve-in-valve procedure was considered the best option. A transfemoral valve-in-Lotus implantation with a SAPIEN 3 valve (Edwards Lifesciences Inc., Irvine, CA, USA) was performed. Preinterventional CT measurements showed an expanded Lotus prosthesis with a mean diameter of 23.2 mm and an area of 412 mm². A 26-mm SAPIEN 3 valve was selected.

Results: Successful implantation was achieved without complications. Due to a short distance of the coronary ostia to the annulus area and to avoid coronary obstruction, a lower valve position was chosen. For placement, the fluoroscopic middle marker of the SAPIEN 3 was positioned just above the lower crown of the Lotus valve. After implantation a moderate residual paravalvular regurgitation was detected at angiography and transesophageal echocardiography originating between the two transcatheter valves, it was decided to perform a postdilatation. After postdilatation, echocardiographic and angiographic assessment showed a trivial paravalvular regurgitation. A final peak-to-peak gradient of 1 mm Hg was measured.

Conclusion: The patient recovered uneventfully. She was able to walk around the ward on day 3 and was discharged in good clinical condition on day 11. This is the first report of a valve-in-valve implantation of a SAPIEN 3 in an early degenerated Lotus valve. We could demonstrate technical feasibility and clinical efficacy of this procedure.