Emergency "Valve-in-Valve" TAVR for Severe Mixed Bioprosthetic Aortic Valve Dysfunction Complicated by Refractory Cardiogenic Shock
Poster #: 199
Session/Time: B
Author:
Juan Munoz Moreno, MD
Mentor:
Johanna Contreras, MD, MSc
Research Type: Case Report
Abstract
INTRODUCTION:
Bioprosthetic aortic valve dysfunction can present as a life-threatening emergency, such as refractory cardiogenic shock (CS). In high-risk patients with structural degeneration of a prior transcatheter valve, emergency valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) can be lifesaving by rapidly restoring hemodynamic stability.
CASE INFORMATION:
A 71-year-old woman with hypertension and prior TAVR eight years earlier presented with progressive dyspnea over three months. Physical examination revealed JVD, a holosystolic ejection murmur with diminished aortic component, and bilateral pulmonary crackles. TTE showed LVEF 46% and severe bioprosthetic degeneration with mixed dysfunction: mean gradient 79 mmHg, peak velocity 5.7 m/s, valve area 0.35 cm², and moderate regurgitation. Despite diuretics and vasodilators, she progressed to refractory CS with pulmonary edema and multiorgan failure, requiring mechanical ventilation, vasopressors, and inotropes. TEE showed severe prosthetic stenosis and severe aortic regurgitation, with LVEF decreased to 10%. Deemed inoperable due to prohibitive surgical risk, she underwent emergency transfemoral ViV TAVR with a 25-mm Navitor valve, leading to rapid hemodynamic improvement and weaning of vasoactive support. Post-procedural TEE showed LVEF recovery to 27% with no residual gradient or regurgitation. On day 21, follow-up TTE revealed a mean gradient of 27 mmHg, raising concern for subclinical leaflet thrombosis. A vitamin K antagonist was initiated, and cardiac CT confirmed a 2-mm thrombus on the right coronary cusp. After 11 days of anticoagulation, repeat imaging showed complete thrombus resolution and restored prosthetic function. The patient was discharged in stable condition and remained asymptomatic at one-year follow-up.
DISCUSSION:
The ACC/AHA guidelines support ViV TAVR for severe bioprosthetic aortic valve dysfunction in patients at high or prohibitive surgical risk.¹ In CS, TAVR may stabilize hemodynamics despite the elevated procedural risk. The immediate improvement in blood pressure and LVEF suggests reversal of myocardial stunning through afterload reduction and preload optimization. Registry data from PARTNER-2 demonstrated 30-day and one-year mortality of 2.7% and 12.4%, respectively, in high-risk patients.² Bioprosthetic valve thrombosis, often subclinical, is most common within three months post-implant. CT is the diagnostic modality of choice, and vitamin K antagonist therapy is recommended to restore function.¹
CONCLUSION:
Emergency valve-in-valve TAVR can interrupt the downward spiral of refractory CS in selected patients with severe bioprosthetic valve dysfunction. In this case, timely intervention led to rapid hemodynamic stabilization and myocardial recovery. Ongoing surveillance is critical for detecting early complications such as subclinical leaflet thrombosis.
Bioprosthetic aortic valve dysfunction can present as a life-threatening emergency, such as refractory cardiogenic shock (CS). In high-risk patients with structural degeneration of a prior transcatheter valve, emergency valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) can be lifesaving by rapidly restoring hemodynamic stability.
CASE INFORMATION:
A 71-year-old woman with hypertension and prior TAVR eight years earlier presented with progressive dyspnea over three months. Physical examination revealed JVD, a holosystolic ejection murmur with diminished aortic component, and bilateral pulmonary crackles. TTE showed LVEF 46% and severe bioprosthetic degeneration with mixed dysfunction: mean gradient 79 mmHg, peak velocity 5.7 m/s, valve area 0.35 cm², and moderate regurgitation. Despite diuretics and vasodilators, she progressed to refractory CS with pulmonary edema and multiorgan failure, requiring mechanical ventilation, vasopressors, and inotropes. TEE showed severe prosthetic stenosis and severe aortic regurgitation, with LVEF decreased to 10%. Deemed inoperable due to prohibitive surgical risk, she underwent emergency transfemoral ViV TAVR with a 25-mm Navitor valve, leading to rapid hemodynamic improvement and weaning of vasoactive support. Post-procedural TEE showed LVEF recovery to 27% with no residual gradient or regurgitation. On day 21, follow-up TTE revealed a mean gradient of 27 mmHg, raising concern for subclinical leaflet thrombosis. A vitamin K antagonist was initiated, and cardiac CT confirmed a 2-mm thrombus on the right coronary cusp. After 11 days of anticoagulation, repeat imaging showed complete thrombus resolution and restored prosthetic function. The patient was discharged in stable condition and remained asymptomatic at one-year follow-up.
DISCUSSION:
The ACC/AHA guidelines support ViV TAVR for severe bioprosthetic aortic valve dysfunction in patients at high or prohibitive surgical risk.¹ In CS, TAVR may stabilize hemodynamics despite the elevated procedural risk. The immediate improvement in blood pressure and LVEF suggests reversal of myocardial stunning through afterload reduction and preload optimization. Registry data from PARTNER-2 demonstrated 30-day and one-year mortality of 2.7% and 12.4%, respectively, in high-risk patients.² Bioprosthetic valve thrombosis, often subclinical, is most common within three months post-implant. CT is the diagnostic modality of choice, and vitamin K antagonist therapy is recommended to restore function.¹
CONCLUSION:
Emergency valve-in-valve TAVR can interrupt the downward spiral of refractory CS in selected patients with severe bioprosthetic valve dysfunction. In this case, timely intervention led to rapid hemodynamic stabilization and myocardial recovery. Ongoing surveillance is critical for detecting early complications such as subclinical leaflet thrombosis.