Redo AVR for Paravalvular Leak Following TAVR

The patient was an eighty-two-year-old man with severe ostial LAD stenosis, paroxysmal atrial fibrillation, and paravalvular leak in a two-year-old TAVR valve. The operation was performed via median sternotomy, followed by the harvesting the left internal mammary in a pedicle fashion. The pericardium was opened and suspended. Then, heparin was given. After reaching an ACT of above 480, cardiopulmonary bypass (CPB) was initiated via central aortic and venous cannulation. A retrograde cardioplegia catheter was then inserted in the coronary sinus. After that, right side pulmonary vein isolation was performed in the beating heart, and after arresting the heart, the left side pulmonary vein isolation was performed. This was followed by left atrial appendage clip ligation.  

Next, the left anterior descending artery was identified and dissected. An 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. After this, the ascending aorta was opened near the sinotubular junction. The previous TAVR valve was inspected carefully until we identified the site of the paravalvular leakThe explant of the TAVR valve was then 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 out carefully and meticulously around the aortic valve annulus using both a size 15 blade and Metzenbaum scissors. Then, 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  rongeur and suction to debride and decalcify the whole annulus. After sizing, we opted for size 27 aortic valve prosthesis. After that, we placed annular pledgeted sutures around the annulus. All these sutures were then passed into the bioprosthesis, and the valve was tied down. The new aortic valve prosthesis looked like it was very well seated with no evidence of any paravalvular gaps. Both coronary ostia were inspected and looked intact. This was followed by closure of the arteriotomy in two layers. The first layer was a 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. After this, a Medistim flow probe was used to check the flow of the left internal mammary artery.Everything 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 postoperative day 1 and discharged home on postoperative day 4. 

References

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.

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