FIRST REPORTED DELAYED REPAIR OF PARAVALVULAR LEAK POST TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)
INTRODUCTION: While surgical aortic valve replacement (SAVR) has long been the standard for aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR) has become increasingly more common, particularly in populations at high risk for adverse surgical outcomes. While it is considered safer in this regard, it is nonetheless associated with a variety of non-surgical valvular, cardiovascular, pulmonary and hematologic complications. Notably, paravalvular leak (PVL) is estimated to occur after 85% of cases of TAVR, and persisting for 1 year in 75% of cases. PVL presents within a relatively brief window of time (median = 4 months) and it is typically repaired within a short period of time. PVL is associated with several risk factors, including annular calcification and endocarditis, and estimates of 10-year survival after the procedure range from 30% to 88%.
STUDY PURPOSE: This study discusses a case of percutaneous PVL repair taking place approximately 6 months after a TAVR procedure. While cases of PVL incidence and subsequent repair that exceed 6 months after SAVR are present in the current literature, we could not find this same timespan in TAVR cases, particularly considering that the onset of PVL symptoms and repair spanned the majority of those 6 months.
CASE REPORT: An 83-year old woman underwent TAVR in March 2016. During this procedure, a presumed wire perforation caused left ventricular injury and tamponade, the latter requiring drainage of the pericardial effusion. We presume that PVL was likely present at the time of this procedure, but could not be repaired due to the aforementioned complications. It is likely that the surgical team at this hospital chose to pursue aggressive pharmacological therapy to mitigate symptoms while the left ventricular wall healed. Following the procedure, the patient presented to us approximately six months later complaining of severe exertional dyspnea following the procedure, which did not resolve itself (NYHA Class III dyspnea with exertion). She denied any anginal symptoms, palpitations, syncope or bleeding. She reported difficulty pronouncing words correctly for one month following the procedure, but this resolved itself. She denied any stroke-like symptoms, including slurred speech, unilateral weakness or paralysis, facial droop or changes in vision. She denied cough and dyspnea at rest.
A TEE demonstrated moderate aortic PVL. History obtained at this time did not reveal any changes, including the persistence of severe exertional dyspnea. Significant physical exam findings included transmission of murmur to the right carotid, no JVD, harsh early peaking grade 2/6 systolic ejection murmur, blowing grade 2/6 decrescendo in the left sternal border, lack of S3, peripheral pulses 2+, and lack of peripheral edema.
Repair of the PVL by balloon aortic valvuloplasty was completed in October 2016. While calcification of the native aortic valve prevented optimal balloon expansion during the first two attempts, this was ultimately accomplished after two successful inflations. TEE demonstrated a trivial leak. Supravalvular aortography demonstrated no evidence of aortic insufficiency.
DISCUSSION/CONCLUSION: To our knowledge, this is the first case study in the current literature describing a case of PVL repair 6 months after the original TAVR. The success of balloon aortic valvuloplasty in the repair of PVL provides a promising outlook for future cases that follow a similar timeline. Continuing follow-up, we will be able to report on the natural history of this case, and provide a point of comparison against cases where the interval between TAVR and PVL repair is shorter.