TAVR as Salvage Therapy for Chronic Decompensated Aortic Regurgitation of a Bioprosthetic Valve

Background: Chronic decompensated aortic regurgitation is the dreaded complication of longstanding untreated aortic regurgitation. This case highlights the importance of early recognition of decompensated aortic regurgitation and underscores the need for urgent valve-in-valve TAVR as a salvage intervention in patients with cardiogenic shock secondary to structural valve deterioration of bioprosthetic valves.

Methods: A 65-year-old male presented to the emergency department (ED) with worsening shortness of breath (SOB) for his third hospitalization in a month.
He has the following past medical history: coronary artery bypass grafting in 2014 (CABG x3- LIMA to LAD, rSVG to RCA, rSVG to OM branch), history of bioprosthetic aortic valve replacement [AVR] in 2014 for aortic stenosis with aortic insufficiency with a 23 mm Trifecta, hypertension, hyperlipidemia, and tobacco use disorder. Within hours of his previous discharge, the patient developed acute hypoxic respiratory failure and was re-admitted to the HVICU on non-invasive positive pressure ventilation. BNP increased to 4979 pg/mL, and troponin was 1299 ng/L. He was aggressively diuresed and eventually optimized to undergo transesophageal echocardiography (TEE) as demonstrated in Video 1. His TEE demonstrated severe aortic regurgitation, and given his acute clinical presentation, a right and left heart catheterization was pursued in anticipation of surgical aortic valve replacement evaluation as demonstrated in Slides 6-9. During the procedure, the patient developed acute hypoxic and hypercapnic respiratory failure requiring mechanical ventilation and was started on inotopic support. He was re-admitted to the HVICU in Stage B cardiogenic shock where aggressive decongestion and afterload strategies were initiated.

Outcome: His calculated STS score was 70 and he was taken for urgent valve-in-valve TAVR given his acute deterioration and extremis condition.
A VALVE SAPIEN 3 ULTRA RESILIA TRANSCATHETE HEART 20MM was utilized with evidence of moderate patient prosthesis mis-match that was expected

Conclusion: The use of valve-in-valve TAVR for structural deterioration of bioprosthetic valves in patients with acute or chronic decompensated aortic regurgitation serves as a salvage strategy that requires a multidisciplinary team. Additionally, the hemodynamic support poses a challenge given the limitations and contraindications to MCS in aortic regurgitation.