Abstract
New technology advances in transcatheter aortic valve implantation (TAVI) promise to improve outcomes and usability. The next generation Direct Flow Medical (DFM) valve is a non metallic, repositionable and retrievable bioprosthesis with a flexible system that provides an optimal circumferential seal. We report a case of TAVI complicated by massive aortic regurgitation after balloon aortic predilation. This case demonstrates that the design and delivery mode of the DFM valve is advantageous during this emergency situation.
Highlights
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Severe aortic regurgitation after balloon valvuloplasty is a potentially serious complication.
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The direct flow medical valve consists of a flexible system with two independent inflatable rings.
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We present a case showing that this valve is advantageous during this emergency situation.
1
Introduction
Transcatheter aortic valve implantation (TAVI) technology is continuously evolving. The Direct Flow Medical (DFM) valve (Direct Flow Medical Inc., Santa Rosa, California) aims to improve clinical outcomes by providing an optimal placement, repositioning, and annular sealing that minimizes paravalvular leak . The inflatable non-metallic design and implantation technique requires a new implantation procedure that could affect the speed of valve deployment. We report a patient with severe aortic stenosis (AS) undergoing TAVI with the DFM valve that developed severe acute aortic regurgitation (AR) and cardiogenic shock after balloon aortic valvuloplasty (BAV), and thus required rapid valve implantation.
2
Case report
A 79-year-old woman with a history of hypertension, dyslipidemia and chronic kidney disease presenting with progressive dyspnea was diagnosed with severe AS. The transthoracic echocardiogram showed an elevation of the aortic transvalvular gradient (mean gradient of 64.7 mmHg), an aortic jet velocity of 5.05 m/s, an aortic valve area of 0.62 cm2, mild aortic regurgitation and preserved left ventricular systolic function. Computed tomography revealed a tricuspid aortic valve with eccentric calcification and an aortic annulus diameter of 29 × 22 mm ( Fig. 1 ). After evaluation by our heart team, the patient was selected to undergo TAVI (Logistic EUROSCORE was 22.97% and STS score was 5.5%), and met all criteria for inclusion in the Direct Flow Discover Trial . The procedure was performed transfemorally (via an 18 French sheath) under general anesthesia. Baseline arterial blood pressure was 144/55 mmHg, and the left ventricular end diastolic pressure (LVEDP) was 15 mmHg ( Fig. 2 A ). Valve pre-dilation was performed using a 25 mm diameter balloon under rapid pacing ( Fig. 2 B). Soon after BAV, the systolic arterial blood pressure decreased to below 60 mmHg, and the LVEDP was increased (28 mmHg) ( Fig. 2 C), due to severe AR that was confirmed on aortography ( Fig. 2 D and video ). A 27 mm DFM valve was rapidly advanced into the left ventricle. The lower ventricular ring was pressurized. Despite the valve being well below the annulus, the valve partially functioned that led to improvement of severe AR ( Fig. 3 A ) and the systolic blood pressure increased progressively to > 100 mmHg ( Fig. 3 B).
