Valve-in-valve TAVR and Bioprosthetic Valve Fracture in a Patient at High Risk of Coronary Obstruction using the J-Valve System

History: A 78 Female was referred to the heart team with NYHA class III symptomatic severe stenosis of a 21mm Magna surgical aortic valve that had been inserted in 2006. Other comorbidities included permanent pacemaker insertion for complete heart block following aortic valve replacement and obstructive sleep apnea.

Angiography or other diagnostic tests: Transthoracic echocardiography showed normal systolic function and severe stenosis of the surgical bioprosthesis (mean gradient 32mmHg, aortic valve area 0.9cm²). Coronary angiography demonstrated normal coronary arteries. Aortic root angiography was concerning for risk of coronary obstruction with valve-in-valve TAVR. This risk was confirmed with computed tomography; simulation of insertion of a 20mm transcatheter heart valve (THV) demonstrated flush occlusion of the right coronary artery and a virtual THV to coronary distance of 3mm to the left coronary artery.

Procedure: A 21mm J-Valve was implanted via transapical approach. Coronary flow was not compromised. Post implant, transvalvular gradient was elevated at 22mmHg and so bioprosthetic valve fracture was performed with a 21mm TRUE balloon. This decreased the transvalvular gradient to 5mmHg. Post-procedural transthoracic echo demonstrated a mean gradient of 12mmHg with no paravalvular leak.

Conclusion: The use of the J-Valve allowed valve-in-valve TAVR in a patient at high risk of coronary obstruction without requirement for coronary protection or other complex techniques such as BASILICA.