Two cases of sudden leaflet dehiscence after transcatheter aortic valve replacement

Abstract

Background
Transcatheter aortic valve replacement (TAVR) has caused a paradigm shift in the treatment of severe aortic stenosis. Although less invasive and good early results of TAVR have been reported, the long-term durability of the transcatheter aortic valve is still unclear.

Case presentation
We performed an emergent surgical aortic valve replacement (SAVR) for two cases of acute heart failure due to sudden transcatheter aortic valve dehiscence after 7 or 6 years of primary TAVR. In both cases, transthoracic echocardiography revealed severe transvalvular regurgitation of the transcatheter aortic valve. Intraoperative findings revealed dehiscence on both sides of the anatomical non-coronary cusp without evident signs of degeneration, such as thickening, calcification, or infection. The postoperative course of the cases was uneventful, and the patients were discharged home on days 20 and 48 after the reoperation.

Conclusions
Although the cause of the valvular disease is unknown, we are seriously concerned that the number of similar cases will increase in the future. We should be cautious in expanding the application of TAVR without evidence of long-term safety.

Full text

Araietal.
General Thoracic and Cardiovascular Surgery Cases (2022) 1:10
https://doi.org/10.1186/s44215-022-00011-4
CASE REPORT
Two cases ofsudden leaet dehiscence
aftertranscatheter aortic valve replacement
Yoshio Arai1,2*, Akira Marui2, Atsushi Nagasawa2 and Nobuhisa Ohno2
Abstract
Background: Transcatheter aortic valve replacement (TAVR) has caused a paradigm shift in the treatment of severe
aortic stenosis. Although less invasive and good early results of TAVR have been reported, the long-term durability of
the transcatheter aortic valve is still unclear.
Case presentation: We performed an emergent surgical aortic valve replacement (SAVR) for two cases of acute
heart failure due to sudden transcatheter aortic valve dehiscence after 7 or 6 years of primary TAVR. In both cases,
transthoracic echocardiography revealed severe transvalvular regurgitation of the transcatheter aortic valve. Intra-
operative findings revealed dehiscence on both sides of the anatomical non-coronary cusp without evident signs of
degeneration, such as thickening, calcification, or infection. The postoperative course of the cases was uneventful, and
the patients were discharged home on days 20 and 48 after the reoperation.
Conclusions: Although the cause of the valvular disease is unknown, we are seriously concerned that the number of
similar cases will increase in the future. We should be cautious in expanding the application of TAVR without evidence
of long-term safety.
Keywords: Transcatheter aortic valve replacement, Structural valve failure, Prosthetic valve deterioration, Reoperation
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Background
Transcatheter aortic valve replacement (TAVR) has
caused a paradigm shift in the treatment of severe aor-
tic stenosis (AS). Although less invasive and good early
results of TAVR have been reported, the long-term dura-
bility of the transcatheter aortic valve is still unclear. We
experienced two cases of surgical aortic valve replace-
ment (SAVR) for acute heart failure due to sudden tran-
scatheter aortic valve dehiscence mid-term after primary
TAVR.
Case presentation
Case 1
A 77-year-old man with a history of rheumatic fever
underwent transfemoral TAVR (SAPIEN XT 26 mm)
accompanied by percutaneous transseptal mitral com-
missurotomy for AS and moderate mitral valve stenosis
with severe calcified aorta. His postoperative course was
uneventful. He underwent pacemaker implantation 1
year after a primary TAVR due to atrial fibrillation with
bradycardia. ereafter, regular follow-up with transtho-
racic echocardiography (TTE) revealed no signs of aor-
tic valve dysfunction. Six years after the primary TAVR
(83 years old), the patient was brought to the emergency
department with sudden chest pain and severe dyspnea.
Chest radiography revealed severe pulmonary edema.
Transthoracic echocardiography showed previously
unobserved severe aortic regurgitation (AR) at the ana-
tomical non-coronary cusp (Fig. 1). Emergent surgical
aortic valve replacement (SAVR) was planned because of
Open Access
General Thoracic and
Cardiovascular Surgery Cases
*Correspondence: yoshioarai@leaf.ocn.ne.jp
1 Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima-cho,
Tenri, Nara 632-8552, Japan
Full list of author information is available at the end of the article

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Araietal. General Thoracic and Cardiovascular Surgery Cases (2022) 1:10
the medically uncontrollable acute AR. Median sternot-
omy was performed, cardiopulmonary bypass was estab-
lished, and cardiac arrest was achieved by retrograde
cardioplegia. Operative findings revealed leaflet dehis-
cence of the prosthetic valve located at one of the cusps,
deviating to the left ventricle (Fig.2). ere were less val-
vular organic changes, such as calcification and degen-
eration, and no obvious signs of infection. e valve was
removed without damaging the perivalvular structures.
Next, the right side of the left atrium was incised, and
the left atrial appendage was closed. Mitral valve replace-
ment (Epic 29 mm: St. Jude Medical, St. Paul, MN) was
then performed, followed by SAVR using a bioprosthetic
valve (Avalus 23 mm: Medtronic, Santa Rosa, CA), and
finally, a tricuspid ring annuloplasty (Tri-Ad 30 mm:
Medtronic, Santa Rosa, CA) was performed. Weaning
from the cardiopulmonary bypass was smooth and easy.
Postoperatively, the patient required continuous hemodi-
alysis for 4 days. e patient was transferred to the gen-
eral ward on the 13th postoperative day and discharged
on postoperative day 48.
Case 2
A 72-year-old man with a history of coronary artery
bypass surgery (60 and 62 years old) underwent trans-
femoral TAVR (SAPIEN XT 26 mm). His postopera-
tive course was uneventful. Regular follow-up with TTE
revealed no signs of aortic valve dysfunction. Six years
after the primary TAVR (79 years old), the patient sud-
denly experienced chest tightness and respiratory dis-
tress. e patient was transported to a local hospital.
He was diagnosed with acute heart failure without sig-
nificant electrocardiographic changes or elevated cardiac
enzyme levels. Transthoracic echocardiography showed
moderate-to-severe AR in the prosthetic valve. Coronary
angiography revealed 90% stenosis of the great saphen-
ous vein bypass graft in the posterior descending branch
of the right coronary artery, and a drug-eluting stent was
implanted in the same area. However, the patient devel-
oped decompensated heart failure, which resulted in
marked pulmonary congestion. Emergent surgical aor-
tic valve replacement (SAVR) was planned because of
the medically uncontrollable acute AR. e patient was
transferred to our institution for an emergency surgery.
On admission, TTE revealed a severe transvalvular AR
(Fig.3). Median sternotomy was performed, cardiopul-
monary bypass was established, and cardiac arrest was
Fig. 1 Preoperative transesophageal echocardiographic view of case 1
Fig. 2 Photograph of the extraction transcatheter heart valve of case
1

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Araietal. General Thoracic and Cardiovascular Surgery Cases (2022) 1:10
achieved by retrograde cardioplegia. Operative findings
revealed leaflet dehiscence of the prosthetic valve located
at one of the cusps, deviating to the left ventricle (Fig.4).
ere were less valvular organic changes, such as calcifi-
cation, degeneration, and no obvious signs of infection.
e valve was removed without damaging the perivalvu-
lar structures, and SAVR was performed using a biopros-
thetic valve (Inspiris Resilia 21 mm: Carpentier-Edwards,
Irvine, CA). Weaning from the cardiopulmonary bypass
was smooth and easy. e patient’s postoperative course
was uneventful. He was transferred to the referral hospi-
tal for rehabilitation on postoperative day 13.
Discussion andconclusions
Although there have been some reports of self-expanding
valvular rupture early after a primary TAVR [1], there has
been, within the scope of our search, no report on emer-
gent SAVR for acute AR due to sudden dehiscence of the
prosthetic valve leaflet of balloon-expandable long-term
after a primary TAVR. From October 2013, when insur-
ance coverage of TAVR began in Japan, until April 2021,
when the procedure was performed in this reported case,
we performed TAVR for 1303 patients at our institu-
tion alone. During this period, only six (0.5%) patients
had unscheduled reoperation after TAVR, requir-
ing a repeat surgery. Prosthetic valve cusp rupture, as
described above, has also been reported in bioprosthetic
valves implanted via SAVR. One study reported a val-
vular leaflet rupture of the Carpentier-Edwards Magna
Ease (Edwards Lifesciences Corp., Irvine, CA, USA) [2],
which is similar to SAPIEN XT (Edwards Lifesciences),
8.7 years postoperatively. During the development of the
SAPIEN XT, endurance tests were conducted for 200
million beats, equivalent to 25 years of heartbeats, and
the results were reported to be comparable to those of
Carpentier-Edwards Magna Ease [3]. e SAPIEN XT
transcatheter heart valves (THV) removed in the cur-
rent surgeries were validated by the Edwards Lifesciences
Corporation, and manufacturing problems have not been
reported. In both cases, the THV was implanted over-
sized and post-BAV was performed, which may have
placed excessive stress on the THV. Unfortunately, no
Fig. 3 Intraoperative transesophageal echocardiographic view of case 2
Fig. 4 Photograph of the extraction transcatheter heart valve of case 2

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Araietal. General Thoracic and Cardiovascular Surgery Cases (2022) 1:10
histological evaluation was performed. It is generally
stated that bioprosthetic valves may deteriorate over time
due to the deposition of calcareous components, growth
of autologous tissue, and adhesion of thrombi [4].
e difference in the sewing method between the SAVR
and TAVR valve leaflets may possibly have an effect, but
unfortunately, a public documentation about how to fix
SAVR and TAVR prosthesis leaflets is not provided by the
manufacturing company.
Additionally, it has been reported that the durability of
surgical bioprosthetic valves is inadequate for younger
patients compared to older patients [5], and the current
recommendation of preferring older patients for TAVR is
appropriate until the long-term results become clearer.
TAVR valve removal requires care, and we carefully
detached the frame and intima from the top of the tran-
scatheter aortic valve in a circumferential fashion, bend-
ing the valve as we detached it. Nakazato etal. reported
an interesting method of removing the valve by cutting
the frame longitudinally with nippers to release the radial
force [6].
e cause of acute AR in these cases is unclear. Both
patients underwent regular follow-ups with TTE and
periodic medication adjustments. Patient 1 had under-
gone a scheduled follow-up 10 days prior to symptom
onset. At that time, the patient had no symptoms of heart
failure, TTE showed mild paravalvular AR related to
SAPIEN XT THV, and the examining physician consid-
ered the patient to be doing well. e patient presented
with acute heart failure and was suspected to have acute-
onset severe prosthetic valve dysfunction. We surmised
that the sudden rupture of the prosthetic valve leaflet and
the resulting gap caused severe AR, leading to acute heart
failure. Patient 2 had no heart failure symptoms 1 year
prior to onset, and on TTE, there was only mild paraval-
vular AR related to SAPIEN XT. Six months prior to the
TTE, the paravalvular AR was rated as mild to moder-
ate. During the next 6 months, the valve leaflet ruptured,
which caused severe AR, leading to acute heart failure.
Additionally, the worsening of AR from mild to moderate
at 1-year and 6-month follow-up may have been a predic-
tor of this event. Placement of a THV inside a transcath-
eter aortic valve (TAV-in-TAV) has been reported as an
effective procedure [7]. Since this was a high-risk patient
with a history of twice coronary artery bypass grafting
procedures, we would have preferred performing TAV-
in-TAV. We had to select SAVR because TAV-in-TAV is
not covered by insurance in Japan at present. Approval
for TAV-in-TAV in Japan is anticipated.
On the other hand, a new problem has occurred. TAV-
in-TAV increased the risks for technically impossible
coronary access or coronary obstruction, valve thrombo-
sis, and aortic regurgitation due to perivalvular leakage.
Mauler-Wittwer etal. reported that TAV-in-TAV was not
suitable in 30% of cases due to anatomical limitations and
that it was not always feasible [8]. In a report on aortic
valve reintervention after TAVR in a real-world multi-
center registry, Fukuhara etal. reported that the number
of reinterventions increased and TAVR explants among
all reintervention procedures are increasing year by year
[9].
Currently, SAPIEN XT is not used in Japan, and a mod-
ified version, SAPIEN 3, is in use. Pibarot etal. reported
that SAPIEN XT had more events than surgical valves
over 5 years, but SAPIEN 3 was comparable to surgical
valves [10]. SAPIEN 3 is expected to have good durabil-
ity. Our institution has never experienced leaflet dehis-
cence with SAPIEN 3. However, it has been only 5 years
since the introduction of SAPIEN 3 in Japan, and no
conclusion can be drawn. Continued careful follow-up is
required.
In conclusion, although the cause of the valvular dis-
ease is unknown, we are seriously concerned that the
number of similar cases will increase in the future. We
should be cautious in expanding the indications of TAVI
without evidence of long-term safety.
Abbreviations
TAVR: Transcatheter aortic valve replacement; TTE: Transthoracic echocardiog-
raphy; AR: Aortic regurgitation; SAVR: Surgical aortic valve replacement; THV:
Transcatheter heart valve; TAV: Transcatheter aortic valve.
Acknowledgements
Not applicable
Authors’ contributions
YA prepared a draft of the report and collected the data. AM edited the manu-
script and supervised the study. AN and NO collected the data. All authors
reviewed and revised the manuscript. All authors have read and approved the
final manuscript.
Funding
There is no funding source.
Availability of data and materials
Data sharing is not applicable to this article, as no datasets were generated or
analyzed during the current study.
Declarations
Ethics approval and consent to participate
Because of the retrospective nature of this study, the requirement for written
informed consent was waived. Additionally, approval by the ethical review
board was waived in this case report because a case report does not require
approval by the review board of our hospital.
Consent for publication
Written informed consent was obtained from the patient for the publication
of the case report and any accompanying images.
Competing interests
Yoshio Arai, MD, is the proctor of transcatheter aortic valve implantation
for Edwards Lifesciences. The remaining authors declare that they have no
competing interests.

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Author details
1 Department of Cardiovascular Surgery, Tenri Hospital, 200 Mishima-cho, Tenri,
Nara 632-8552, Japan. 2 Department of Cardiovascular Surgery, Kokura Memo-
rial Hospital, 3-2-1 Asano, Kokurakita-ku, Kitakyushu City, Fukuoka 802-8555,
Japan.
Received: 10 June 2022 Accepted: 31 August 2022
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