Predicted Coronary Occlusion and Impella Salvage During Valve-in-Valve Transcatheter Aortic Valve Replacement

Case report: management of refractory cardiogenic shock with Impella 5.5 in patients with transcatheter aortic valves

Background

Impella is a transaortic valvular pump commonly utilized in patients with cardiogenic shock. However, its use with transcatheter aortic valves (TAVI) remains rare. We present two cases where surgical Impella 5.5 was placed across both Sapien 3 Ultra and Evolute Pro+ valves.

Case summary

Patient 1: A 74-year-old male with history of ischaemic cardiomyopathy with ejection fraction 20-25% status post-cardiac resynchronization therapy with a defibrillator, severe aortic stenosis (AS) status post-recent Sapien 3 Ultra TAVI presented with cardiogenic shock. Due to persistent unstable haemodynamic status, Impella 5.5 was placed and was utilized as a bridge to left ventricular assist device. Patient 2: A 74-year-old male with a history of alcoholic cirrhosis and AS underwent Evolute Pro+ TAVI at outside facility. The implantation was complicated by left main coronary artery occlusion, leading to cardiogenic shock. Patient required femoral veno-arterial extracorporeal membrane oxygenation (ECMO) support and emergent single vessel coronary bypass of a saphenous venous graft to the left anterior descending artery. Extracorporeal membrane oxygenation was decannulated on Day 20 and Impella 5.5 was placed as a bridge to recovery. In both cases, there were no procedural complications or residual aortic or perivalvular regurgitation.

Discussion

Impella 5.5 implanted via the axillary surgical cutdown is safe and feasible approach to manage refractory cardiogenic shock in patients with TAVI including different types of valves, Sapien 3 Ultra, and Evolute Pro+. As it can provide full haemodynamic support, Impella 5.5 can be used as bridge to recovery or durable mechanical support.

Report of Accidental Anchoring of an Impella Device to a Perceval Bioprosthesis in a Patient

We herein report a case in which we encountered complications when placing an Impella CP ventricular assist device (catheter-based ventricular assist device) in a patient with a Perceval bioprosthetic valve (sutureless valve). Specifically, the catheter-based ventricular assist device became anchored to the sutureless valve and needed to be removed under cardiopulmonary bypass. (Level of Difficulty: Advanced.).

Transcatheter Aortic Valve Replacement With Self-Expandable Supra-Annular Valves for Degenerated Surgical Bioprostheses: Insights From Transcatheter Valve Therapy Registry

Background

Transcatheter aortic valve replacement with supra‐annular transcatheter heart valves has been adopted in patients with degenerated surgical aortic valves. The next generation self‐expanding Evolut PRO valve has not been evaluated in patients with surgical valve failure.

Methods and Results

Patients undergoing transcatheter aortic valve replacement in degenerated surgical aortic valve procedures using the Evolut R or Evolut PRO transcatheter heart valves in the Society of Thoracic Surgeons and American College of Cardiology Transcatheter Valve Therapy Registry between April 2015 and June 2019 were evaluated. Transcatheter valve performance was evaluated by clinical site echocardiography. In‐hospital, 30‐day, and 1‐year clinical outcomes were based on the Society of Thoracic Surgeons‐American College of Cardiology‐Transcatheter Valve Therapy registry definitions. Transcatheter aortic valve replacement in degenerated surgical aortic valve was performed in 5897 patients (5061 [85.8%] patients received the Evolut R valve and 836 [14.2%] received the Evolut PRO valve). Thirty‐day transcatheter heart valves hemodynamic performance was excellent in both groups (mean gradient: Evolut PRO: 13.8±7.5 mm Hg; Evolut R: 14.5±8.1 mm Hg), while paravalvular regurgitation was significantly different between valve types (P=0.02). Clinical events were low at 30 days (Evolut PRO: for the all‐cause mortality, 2.8%, any stroke was 1.8%, new pacemaker implantation, 3.0%: Evolut R:all‐cause mortality, 2.5%, any stroke was 2.2%, new pacemaker implantation, 5.3%) and 1 year (Evolut PRO: all‐cause mortality, 9.2%; any stroke, 3.1%; Evolut R: all‐cause mortality, 9.8%; any stroke, 2.9%).

Conclusions

Transcatheter aortic valve replacement in degenerated surgical aortic valve with self‐expandable supra‐annular transcatheter heart valves is associated with excellent clinical outcomes and valve hemodynamics. Additional reductions in residual paravalvular regurgitation were obtained with the next generation Evolut PRO.

Redo-transcatheter aortic valve replacement with the supra-annular, self-expandable Evolut platform: Insights from the Transcatheter valve Therapy Registry

OBJECTIVES

To assess the safety profile of redo-TAVR procedures from patients in the transcatheter valve therapy (TVT) Registry.

BACKGROUND

The use of transcatheter aortic valves (TAV) to treat previously implanted failing TAVS (TAV-in-TAV) has been an increasingly important topic as indications for TAVR move to younger and lower-risk patients, but data on the safety and efficacy of redo-TAVR is limited.

METHODS

Patients undergoing redo-TAVR procedures using the Evolut R, Evolut PRO or Evolut PRO+ valve in the TVT Registry between April 2015 and March 2020 were included. In-hospital, 30-day and 1-year outcomes were analyzed.

RESULTS

Redo-TAVR was performed in 292 patients (213 patients received the Evolut R valve and 79 received the Evolut PRO or PRO+ valve). Device success was achieved in 94.5%. In-hospital mortality was 2.1%, stroke occurred in 2.7%, and 77.2% of patients were discharged home. There were no cases of coronary compression/obstruction or myocardial infarction that occurred in index hospitalization. Mean gradient at 30-days was 11.9 ± 6.9 mmHg, and 73.1% had none/trace total aortic regurgitation.

CONCLUSIONS

Results from the TVT Registry demonstrate good short-term outcomes after redo-TAVR with the supra-annular, self-expandable Evolut platform. Long-term follow-up is necessary to further expand understanding this complex scenario.