More in, better out? Successful valve-in-valve procedure of an iatrogenic ventricular septal defect following transcatheter aortic valve replacement: a case report

Abstract Background A rare, but serious, complication following transcatheter aortic valve replacement (TAVR) is the occurrence of an iatrogenic ventricular septal defect (VSD). Case summary We describe a case of an 80-year-old female who was referred with severe aortic stenosis for TAVR. Following thorough evaluation, the heart team consensus was to proceed with implantation via a transapical approach of an ACURATE neo M 25 mm valve (Boston Scientific, Natick, MA, USA). The valve was deployed harnessing transoesophageal echocardiographic (TOE) guidance under rapid pacing with post-dilation. Directly afterwards a very high VSD close to the aortic annulus was detected. As the patient was haemodynamically stable, the procedure was ended. The next day another TOE revealed a shunt volume (left-to-right ventricle) between 50% and 60%. Because the defect was partly located between the stent struts of the ACURATE valve decision was made to fix this leakage with implantation of a further valve and we chose an EVOLUT Pro 29 mm (Medtronic Inc., Minneapolis, MN, USA). The valve-in-valve was implanted 2–3 mm below the lower edge of the first valve, more towards the left ventricular outflow tract (LVOT) with excellent result: VSD was reduced to a very small residual shunt without any hemodynamic relevance. Figure 3 (A) Fluoroscopic image after transapical transcatheter aortic valve replacement (ACURATE neo M); (B) transoesophageal echocardiography following transapical transcatheter aortic valve replacement showing a severe ventricular septal defect; (C) angiography after valve-in-valve implantation. The implantation depth of the second valve (EVOLUT Pro 29 mm) was slightly deeper in the left ventricular outflow tract; and (D) transoesophageal echocardiography after the valve-in-valve procedure showing a small residual shunt. (1) Stentstruts, (2) tricuspid valve, and (3) leakage (ventricular septal defect). *Pulmonary artery catheter, #Pleural drain. Figure 4 Left ventricular angiogram after valve-in-valve implantation showing a very small residual contrast shunt from the left-to-right ventricle (encircled). *Pulmonary artery catheter, #Pleural drain. Discussion We suggest that an iatrogenic VSD located near the annulus may be treated percutaneously in a bail-out situation with implantation of a second valve that should be implanted slightly more into the LVOT to cover the VSD.