How to Prepare an Easy Device Landing Zone for Transcatheter Aortic Valve Implantation in Pure Aortic Regurgitation—Proof of Concept

Objectives: Transcatheter aortic valve implantation (TAVI) in pure aortic regurgitation (AR) is challenging because of the subsequent difficulty in anchoring the transcatheter valve in a noncalcified device landing zone (DLZ). Prestenting can help prepare a stable DLZ for TAVI in pure AR, prevent valve migration, and improve device success. In an initial case series, we report the novel technique of uncovered stent implantation into a noncalcified aortic valve as a prestenting strategy to prepare a neo DLZ for TAVI in pure AR.

Methods: Between July 2017 and May 2018, five consecutive patients with pure AR of their native aortic valve and high risk for surgical aortic valve replacement underwent a TAVI procedure (Table 1). To prevent valve migration, an uncovered stent (sinus XL, 40 mm length, OptiMed-Medizinische-Instrumente-GmbH, Ettlingen, Germany) was implanted into the DLZ just before a SAPIEN-3 valve (Edwards Lifesciences, Irvine, California, United States) was deployed in a standard manner. In patients without permanent mechanical circulatory support (n = 2), TAVI was performed under a short duration of cardiopulmonary bypass for safety reasons using percutaneous peripheral cannulation.

Results: According to Valve Academic Research Consortium-II (VARC-II) criteria, device success was achieved in all patients (100%). Postprocedural aortic valve regurgitation was absent in three patients (60%) and trace in two patients (40%). There was no in-hospital mortality. Postprocedural computed tomography scans confirmed a stable position of the SAPIEN-3 valve and the stent inside the DLZ. Beside acute renal failure in one patient (20%), there were no further procedure-related VARC-II events.

Conclusion: TAVI has been shown to be effective in eliminating pure AR but was associated with a high necessity of implantation of a second valve. In our initial case series of five patients, prestenting prepared an easy DLZ for TAVI in pure AR and prevented valve migration. We consider this prestenting technique a useful novel strategy that may be applicable also in patients without mechanical circulatory support, at least as long as specific TAVR devices for pure AR are lacking.

[Table 1]

Pat.	Gender	Age (y)	TAVI indication	EuroSCORE II (%)	Mean annulus diameter (mm)	Sinus XL stent diameter (mm)	TAVI strategy	Device success	Status after TAVI
1	Male	71.8	s/p LVAD	62.4	28.0	32	TF SAPIEN-3 29 mm	Yes	Death after 105 d (right heart failure)
2	Male	77.6	s/p LVAD	10.4	25.8	30	TF SAPIEN-3 29 mm	Yes	Alive after 211 d
3	Male	69.9	s/p LVAD	39.6	25.1	30	TF SAPIEN-3 29 mm	Yes	Death after 13 d (septic MOF)
4	Male	75.6	s/p aortic dissection	2.4	27.3	32	TF SAPIEN-3 29 mm	Yes	Alive after 120 d
5	Female	67.7	Frailty, immobility	6.7	24.5	30	TA SAPIEN-3 29 mm	Yes	Alive after 106 d