Balloon Valvuloplasty for Evolut R Infolding

Prosthesis Infolding Incidence and Short-Term Outcomes in Transcatheter Aortic Valve Implantation Using Evolut Self-Expandable Device: A Multicenter Study

Transcatheter aortic valve implantation (TAVI) is an established treatment strategy in aortic valve disease. Infolding, as a nonuniform expansion of the prosthesis leading to introflection of part of the device circumference, is a complication specific to self-expandable prostheses. The aim of the study is to determine incidence, predictors, treatment strategy, and outcomes of infolding during Medtronic Evolut TAVI (Minneapolis, MN, US). Between January 2018 and March 2022, all patients treated with Evolut TAVI were included in a multicenter observational retrospective study. According to the occurrence of infolding, the enrolled cohort was divided into 2 groups; periprocedural characteristics and 30-day outcomes were compared. A total of 1,470 patients were included; 23 infolding cases (1.6%) were detected. Preprocedural imaging showed larger aortic anatomy and greater calcium burden in the infolding group. Infolding occurred mostly with Evolut Pro+ and size 34 mm and was diagnosed before full prosthesis release in 78.3%. The rate of moderate-to-severe paravalvular regurgitation was higher in the infolding group (21.7% vs 1.9%, p <0.001). Short-term follow-up showed greater all-cause and cardiovascular mortality (respectively, 4.3% vs 0.7% and 4.3% vs 0.6%, p <0.05) and higher rate of pacemaker implantation (33.3% vs 15.7%, p = 0.042) in case of infolding. High right cusp calcium score and resheathing maneuvers were independent predictors of infolding. In conclusion, prosthesis infolding is a TAVI complication burdened by worse cardiovascular outcomes. Prompt intraprocedural infolding diagnosis is pivotal, especially in case of great native valve calcium burden and resheathing maneuvers, to safely overcome this complication by prosthesis recapture or postdilation.

Infolding of Evolut PRO+ during transcatheter aortic valve implantation and bailout by post-balloon dilation: A case report

An 89-year-old man with symptomatic severe aortic stenosis underwent transcatheter aortic valve implantation due to old age and a history of coronary artery bypass grafting. Computed tomography showed a tricuspid aortic valve and severe calcification at the aortic valve annulus, with a perimeter of 88.7 mm. The 34-mm Evolut PRO+ (Medtronic Inc., Minneapolis, MN, USA) was selected. After balloon aortic valvuloplasty, deployment of the Evolut PRO+ was attempted, but significant expansion failure was observed. Upon retraction and removal of the Evolut PRO+ from the body, frame deformation was observed. A new Evolut PRO+ was tried again, but a similar finding was noted as a magatama-like infolding on transesophageal echocardiography. Fortunately, the patient's hemodynamics were relatively stable. Post-dilation was performed using a 25 mm Z-MED II (NuMED, Inc., Montreal, Canada) for reshaping.

Learning objective

In self-expanding transcatheter aortic valves (TAVs), bending of the TAV frame is widely known as one of the key problems. However, this is rare and infrequently encountered. In this case, TAV frame infolding occurred repeatedly, and the morphology of the infolding was evaluated in vitro and in vivo. Furthermore, we report that some TAVs can be reshaped by post-dilation.

Self-expanding transcatheter aortic valve infolding: Current evidence, diagnosis, and management

BACKGROUND

Prosthetic valve infolding is a rare but severe complication of transcatheter aortic valve implantation (TAVI) with self-expanding valves. However, currently available clinical data are limited and fragmented.

OBJECTIVES

This report aims to provide a comprehensive overview of this complication focusing on predisposing factors, clinical presentation, diagnostic findings, treatment and clinical outcomes.

METHODS

A systematic review of the literature was performed to identify cases of infolding occurring during TAVI with self-expanding valves published until August 2020. These data were pooled with all the retrospectively identified infolding cases occurred at San Raffaele Scientific Institute between December 2014 and August 2020.

RESULTS

A total of 34 cases were included. Among patients with available data, 38% received a first-generation CoreValve, and 62% a second-generation Evolut R (82%) or Evolut PRO (18%). Infolding occurred mostly with ≥29-mm valves (94%). Predisposing factors included resheathing of a second-generation valve (82%), heavy calcification of the native valve (65%), lack of predilatation (16%), Sievers type-1 bicuspid aortic valve (11%), and improper valve loading (5%). Infolding resulted in severe PVL causing hemodynamic instability (29%) or cardiac arrest (12%). Postdilatation was the treatment strategy in 68%, while prosthesis replacement with a new device in 23% of cases. Device success rate was 82%. Death and stroke occurred in 3% and 12% of cases.

CONCLUSIONS

Prosthetic valve infolding is typically observed after resheathing of a large-size self-expanding TAVI. When infolding is timely diagnosed, prosthesis removal and replacement should be pursued. Further studies are required to precisely define predisposing factors to prevent this complication.

Infolding of Self-Expandable Transcatheter Heart Valve: Case Report and Review of Literature

Transcutaneous aortic valve replacement (TAVR) has become a widely accepted minimally invasive approach for treatment of severe aortic stenosis. Self-expandable prostheses are commonly the device of choice, with excellent procedural success and durability. However, there have been several recent case reports of infolding of the self-expandable prosthesis during development with subsequent malfunction and need for further intervention. We present a case of self-expandable valve prosthesis infolding managed by balloon postdilation, and summarize the cases reported in the literature to date in an attempt to increase awareness of this serious technical problem and the factors associated with it.