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Transapical Transcatheter Aortic Valve-in-valve Implantation For Aortic Regurgitation With A Self-expandable Device In A Degenerated Homograft.
Gry Dahle, Bjørn Bendz, Jon Offstad, Jan Fredrik Bugge, Kjell Arne Rein.
Rikshospitalet, OUS, Oslo, Norway.

OBJECTIVE: Transcathateter aortic valve implantation (TAVI) has initially been considered as an alternative for high-risk patients with aortic stenosis. Also valve-in-valve (VIV) technique for degenerated bioprosthesis is performed for stented as well as for calcified stentless bioprosthesis. With a new generation of self-expandable devices,VIV for aortic regurgitaion (AR) in a degenerated homograft with regurgitation may be an option
MATERIAL: A 27 years old woman with degenerated calcified homograft with regurgitation was referred for a fifth sternotomy. Initially she had endocarditis in a bicuspid aortic valve replaced by a bioprosthesis. Few months later she developed again endocarditis and reoperated with a Freestyle (Medtronic Inc, Minneapolis, MN) root replacement together with reconstruction of the anterior mitral leaflet. Postoperatively AV block occurred and pacemaker was implanted. Some months afterwards she underwent another Freestyle root replacemant due to recidiv endocarditis. Finally she got a homograft implantation following recidiv endocarditis in the second Freestyle graft. Initially the result looked good with absence of any new endocarditis. However, 7 years later she developed severe aortic regurgitation and dilatation of the left ventricle due to detoriation of the homograft. Another re-do aortic root reconstruction was evaluated complicated. VIV was considered and CT measurements perfomed to evaluate the size of the catheter-valve to be used as well as the implantation angle.
METHODE AND RESULTS: Via a mini left thoracotomy and transapical access, a self-expandable 26 mm Engager™ (Medtronic Inc, Minneapolis, MN) with control arms was implanted in good position. The peroperative angiography showed contrast in both the reimplanteed coronary arteries. There was only trace of paravalvular leak (PVL) intraoperativly which ceased upon the echo control two days later. The patient was extubated in the operation room and mobilzed the following day.
CONCLUSIONS: This case report demostrate the feasibility of transapical transcatheter aortic VIV implantation of the Engager™ valve in a degenerated homograft with aortic regurgitation. This may expand the use of the VIV implantation technique, applicable also in a situation with pure AR.

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