Author + information
- Vuyisile T. Nkomo, MD, MPH∗ (, )
- Rakesh M. Suri, MD, DPhil,
- Sorin V. Pislaru, MD, PhD,
- Kevin L. Greason, MD,
- Lawrence J. Sinak, MD,
- David R. Holmes, MD,
- Verghese Mathew, MD and
- Charanjit S. Rihal, MD
- ↵∗Mayo Clinic, 200 First Street Southwest, Rochester, Minnesota 55905
Delayed downward migration of the SAPIEN transcatheter heart valve (THV) (Edwards Lifesciences Corporation, Irvine, California) is a rare complication after transcatheter aortic valve replacement (TAVR) (1–3). THV migration into the left ventricle has been described 2 to 43 days after deployment and is associated with cardiogenic shock (1,2) or disruption of mitral valve function (3). We describe 2 additional presentations associated with delayed downward THV migration: native valve restenosis and rapid THV degeneration with severe aortic regurgitation. The choice of the size of the THV in both cases was on the basis of 2-dimensional transesophageal echocardiography (TEE)-determined aortic annulus diameter consistent with practice during early experience with TAVR. The aortic annulus area according to computed tomography (CT) or 3-dimensional TEE was not determined. The 2 cases described occurred after the learning curve (4), when ∼100 TAVR procedures had been performed.
A 79-year-old female patient with symptomatic low gradient severe aortic stenosis, aortic valve area of 0.78 cm2, mean gradient of 21 mm Hg (increased to 41 mm Hg with dobutamine), and left ventricular ejection fraction of 40% underwent transapical TAVR with a 23-mm SAPIEN THV (Edwards Lifesciences Corporation). The patient’s Society of Thoracic Surgeons risk score was 15.5%. The TEE long-axis view showed a normal appearance of the THV (Figure 1A, arrows) immediately post-deployment, and there was mild periprosthetic regurgitation and a normal THV gradient of 5 mm Hg. Pre-discharge transthoracic echocardiogram 7 days post-TAVR showed a THV systolic mean gradient of 19 mm Hg and mild regurgitation. At 3 months’ follow-up, the patient complained of recurrent dyspnea, and the THV was noted to have migrated downward, with native leaflets visualized above the THV on TEE imaging (Figure 1B, arrows). The TEE short-axis view displayed the different position of THV commissures (Figure 1C, arrows) and native leaflet commissures (Figure 1D, arrows), and the mean gradient was increased to 23 mm Hg. The patient was subsequently diagnosed with supraprosthetic native valve restenosis, which in retrospect may have occurred earlier (pre-discharge) and was not recognized. She was managed medically.
An 82-year-old male patient with severe aortic stenosis, aortic valve area of 0.93 cm2, mean gradient of 54 mm Hg, left ventricular ejection fraction of 70%, and a Society of Thoracic Surgeons risk score of 9.5% underwent transfemoral TAVR with a 26-mm SAPIEN valve on the basis of a 2-dimensional TEE aortic annulus diameter of 24 mm. There was native leaflet overhang immediately post-THV placement (Figure 1E, arrow) and associated moderate periprosthetic regurgitation. The mean gradient was 12 mm Hg. Periprosthetic regurgitation was mild 7 days post-TAVR; the mean gradient was 20 mm Hg. At 1 year, the patient had recurrent dyspnea and heart failure. TEE demonstrated that the THV gradient was 39 mm Hg and offered evidence of supraprosthetic native aortic valve restenosis on long-axis view (Figure 1F, arrows) and short-axis views and associated severe transprosthetic regurgitation (Figure 1G). The THV leaflets appeared torn. The patient subsequently underwent successful repeat transfemoral valve-in-valve TAVR with a second 26-mm SAPIEN THV placed slightly superior to the first THV (Figure 1H, arrow [before deployment]). There was moderate periprosthetic residual regurgitation despite post-THV deployment balloon dilatation, but native leaflet overhang was eliminated. At 1-year follow-up after the valve-in-valve TAVR, the THV mean gradient was 14 mm Hg, and the degree of periprosthetic regurgitation was mild. In retrospect, the aortic valve annulus diameter according to computed tomography scan measured 28 mm, suggesting that the 26-mm THV was undersized.
Mechanisms responsible for downward THV migration can include native leaflet overhang post-deployment, exerting downward force on the THV (1,2) or limited anchoring of the THV from low deployment in a relatively large and nonseverely calcified annulus (1) or from deployment of a THV that is too small for the native aortic valve annulus. Although rare, delayed THV migration should be suspected when there is a worsening of the patient’s clinical status or unfavorable THV hemodynamic profile (increasing mean gradient or worsening regurgitation) on follow-up echocardiographic examination.
- American College of Cardiology Foundation