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• W2098904458 abstract "Dear Editor We read with interest the case report by Al-Attar et al. [1] regarding the fatal complication of severe intravalvular leak due to an immobile cusp following trans-apical TAVI with 23 mm Edwards-SAPIEN valve. We congratulate the team for sharing their complication which is under reported and at times overlooked. The patient developed rapid severe left ventricular dysfunction despite all attempts to correct the situation failed (including positioning of a second valve-in-valve and the use of femorofemoral Extracorporeal membrane oxygenation). We also noted the editorial comment regarding the possibility of damage to the valve leaflets while hooking the leaflet on the stent during the crimping phase as a possible origin of the irreversible immobility. At our institute, over the past three years, we have implanted over 230 Edward-SAPIEN and XT valves [2]. We have also noted the onset of this complication in two patients. The immobility of the stent valve leaflet was transient and due to inadequate balloon inflation of the valve in the patients. Once the valve is balloon expanded again, the stent fully deployed allowing the valve leaflets to function properly. We do not believe that crimping is the cause but as described by the authors it must be an irregular expansion on the stent, which leads to aortic regurgitation. We think noncircular expansion is the major mechanism, as implanted stented surgical valves are circular and always function well unless there is distortion of the stent during implantation. Also, aortic regurgitation is observed after stentless valve implantation when there is distortion of the stentless valve anatomy, i.e. loss of circular shape. Hence they need expertise and experience to achieve best results [3]. Once implanted the valve opens due to ventricular contraction and closes due to the eddy currents generated [4]. If with adequate pressure head the leaflet function is not satisfactory, then we agree that the only option is implanting another stent with or without circulatory support depending on the degree of regurgitation and haemodynamic stability. In our centre, we performed a case where valve-in-valve implantation was necessary to achieve successful outcome after such a complication. In our experience, we believe it is unlikely that crimping is a cause for this complication. The published literature suggests complications related to the valve mechanism for the Edwards SAPIEN valve, and valve-in-valve implantation or implantation of a second valve being 2.6% [5]. Bearing these observations in mind, we too support the editorial reflections in strongly advocating cardiovascular surgical team present jointly for all TAVI cases, with the facility to go on cardiopulmonary bypass expediently. In our experience the procedure is performed under general anaesthesia with continuous transoesophageal echocardiography. This allows excellent haemodynamic control and visualization of the valve with early identification of the mechanism of valve dysfunction and treatment. In order to expand the application of this technology to moderate risk populations in the near future, we need to ensure that TAVI is performed in highly controlled environment. There needs to be anaesthetic, echocardiographic and surgical team support to lower complications, reduce mortality and achieve excellent outcomes." @default.
• W2098904458 created "2016-06-24" @default.
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• W2098904458 date "2011-11-06" @default.
• W2098904458 modified "2023-09-24" @default.
• W2098904458 title "Severe intraprosthetic regurgitation by immobile leaflet after transcatheter aortic valve implantation" @default.
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• W2098904458 doi "https://doi.org/10.1093/ejcts/ezr034" @default.
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