Discussion
This case demonstrates the successful percutaneous treatment of moderate
central AR present following implantation of an Edwards SAPIEN-3 valve,
secondary to the restricted movement of a valve leaflet. With increasing
use of TAVR for the treatment of severe aortic stenosis, there have been
recent case reports of severe central AR post valve implantation.(3-5)
The incidence of moderate-severe AR reported in the recent PARTNER 3
trail was 0.8% and <=0.2% in the FRANCE-2 registry (French
Aortic National Corevalve and Edwards).(6, 7) The usual mechanisms
causing this prosthetic aortic insufficiency is malfunction secondary to
either a stuck leaflet to an overhanging calcified spicule or native
valve leaflet, or an undersized valve, or due to post-dilatation with an
excessively large balloon which damages the integrity of the valve and
leaflets get stuck.(2, 3, 5) The current advocated approach to treat the
problem is by trying maneuvers such as inserting the pigtail catheter to
dislodge the stuck leaflet or by removing the stiff LV guidewire wire;
but if these fail then a new valve has to be implanted. We present this
case report describing the treatment of moderate AR post TAVR, which has
been resolved by performing balloon valvuloplasty.
We ascertain that the mechanism which helps to restore the function of a
restricted valve leaflet by performing valvuloplasty, is by either
dislodging the leaflet from a calcified spicule or an overhanging native
valve leaflet which is protruding through the valve stent, or by
stretching the valve to its normal size, which could have been
under-expanded in the first instance and valvuloplasty restores its
normal mechanical function. We thus suggest that to the existing module
of treatment options for moderate central AR post TAVR, secondary to
restricted leaflet movement, balloon valvuloplasty should be considered
as an alternative treatment strategy.