Redo AVR for Paravalvular Leak Following TAVR
This is an 82-year-old gentlemen with severe ostial LAD stenosis, paroxysmal atrial fibrillation, and para-valvular leak in a 2-year-old TAVR valve. The operation was performed via median sternotomy, which was followed by harvesting of the left internal mammary in a pedicle fashion. The pericardium was opened and suspended, and then heparin was given. After reaching an ACT of above 480, CPB was initiated via central aortic and venous cannulation. A retrograde cardioplegia catheter was inserted in the coronary sinus. Right side pulmonary vein isolation was done in the beating heart, and after arresting the heart, left side pulmonary vein isolation was done. This was followed by left atrial appendage clip ligation. The left anterior descending artery was identified and dissected. Arteriotomy was performed and then the left internal mammary artery was anastomosed to the LAD in an end-to-side fashion using 7-0 Prolene. The ascending aorta was opened about the sinotubular junction. The previous TAVR valve was inspected carefully until we identified the site of the paravalvular leak. The explant of the TAVR valve was performed en bloc with the native aortic valve. After creating the plane between the native aortic valve leaflets and the aortic annulus, dissection was carried carefully and meticulously around the aortic valve annulus using both a Size 15 blade and Metzenbaum scissors. The remaining parts of the aortic valve leaflet were excised using scissors. This was followed by careful and meticulous debridement and decalcification of the aortic annulus. We used a rongeur and suction to debride and decalcify the whole annulus. Sizing was done and we opted to choose Size 27. After that, we placed annular pledgeted sutures around the annulus. All these sutures were passed into the bioprosthesis and then the valve was tied down. The new aortic valve prosthesis looks like it’s very well seated with no evidence of any paravalvular gaps. Both coronary ostia were inspected and looked intact. This was followed by closure of arteriotomy in two layers. The first layer was horizontal mattress followed by running over and over with Prolene sutures. After performing careful de-airing maneuvers, the clamp was removed, and the patient was weaned successfully from CPB. A Medistim flow probe was used to check the flow of the left internal mammary artery and it was satisfactory. An echocardiogram showed a very well seated valve, no paravalvular leak, and a mean gradient of 4. After achieving good hemostasis, the chest was closed in regular fashion, and the patient was transferred to the ICU. The patient was extubated on POD 1 and she was discharged home on POD 4.
1. Ando T, Adegbala O, Aggarwal A, Afonso L, Takagi H, Grines CL, Briasoulis A. Redo aortic valve intervention after transcatheter aortic valve replacement: Analysis of the nationwide readmission database. Int J Cardiol. 2021 Feb 15;325:115-120. doi: 10.1016/j.ijcard.2020.10.038. Epub 2020 Oct 22. PMID: 33144095.
2. Fanous EJ, Mukku RB, Dave P, Aksoy O, Yang EH, Benharash P, Press MC, Rabbani AB, Aboulhosn JA, Rafique AM. Paravalvular Leak Assessment: Challenges in Assessing Severity and Interventional Approaches. Curr Cardiol Rep. 2020 Oct 10;22(12):166. doi: 10.1007/s11886-020-01418-7. PMID: 33037927.