The management of patients with a failed mechanical aortic valve prosthesis and a porcelain aorta remains one of the most challenging dilemmas in cardiovascular surgery. Conventional re-do surgical aortic valve replacement (SAVR) is often deemed too high-risk due to extensive calcification, vessel fragility, and the risk of catastrophic complications such as stroke or aortic dissection. Transcatheter approaches have offered some hope, but standard retrograde valve-in-valve TAVR is typically contraindicated in cases involving mechanical prostheses due to their rigid structure and potential for interference with transcatheter delivery systems. In this case, a hybrid open transventricular transcatheter aortic valve replacement (TAVR) was successfully implemented as a definitive solution.
The procedure began with a redo midline sternotomy under general anesthesia. The left internal thoracic artery (LITA) and left radial artery (LRA) were harvested for future coronary bypass grafting. A small left lateral thoracotomy was created at the fourth intercostal space, providing access for the TAVR delivery system without requiring rib spreading or formal port placement. Peripheral cardiopulmonary bypass (CPB) was established via femoral arterial and venous cannulation. To avoid the risks associated with aortic cross-clamping in a fragile, calcified vessel, an endovascular occlusion balloon (Reliant Balloon, Medtronic, MN, USA) was introduced through the left femoral artery and positioned in the ascending aorta just below the innominate artery. This allowed controlled temporary occlusion of the ascending aorta during valve manipulation.
Antegrade cardioplegia was delivered via a 6F EBU 3.5 guide catheter advanced into the left main coronary artery through a right radial artery sheath. Retrograde cardioplegia was administered through a coronary sinus catheter, ensuring complete myocardial protection. A left ventriculotomy was then performed, exposing the dehisced mechanical prosthesis. The prosthesis was carefully removed under direct vision, minimizing trauma to surrounding tissues. Pre-procedural multidetector computed tomography had guided the selection of a 29 mm balloon-expandable transcatheter heart valve (Sapien 3, Edwards Lifesciences, CA, USA). The valve was manually trimmed at the nosecone to facilitate passage through the ventriculotomy and advancement toward the aortic occlusion balloon.
Once properly aligned, the valve was deployed under direct visualization using nominal balloon inflation. Post-deployment imaging confirmed correct positioning and adequate sealing. The ventriculotomy was meticulously repaired with running suture technique. Coronary artery bypass grafting was completed using LITA to LAD and LRA to LCx. The patient was weaned from CPB without difficulty. Immediate postoperative angiography revealed mild paravalvular leak, which was not hemodynamically significant.Integrin α5 Antibody Purity & Documentation Transthoracic echocardiography at 30 days showed excellent valve function, with no evidence of structural deterioration or significant regurgitation.LSD1/AOF2 Antibody Description The patient’s NYHA class improved from IV to I, and he resumed full occupational activity by 90 days.PMID:33928590
This case illustrates that open transventricular TAVR is a technically feasible and clinically effective strategy for patients with failed mechanical valves and porcelain aorta. By combining the precision of transcatheter techniques with the control of open surgical access, this hybrid approach circumvents the limitations of both traditional surgery and percutaneous TAVR. It enables complete revascularization, durable valve replacement, and preservation of future intervention options. Success depends on strong institutional support, experienced multidisciplinary collaboration, and meticulous procedural planning. While risks remain—particularly related to bleeding, infection, and arrhythmias—the benefits outweigh alternatives in select high-risk cases. This technique represents a significant advancement in managing complex valvular disease in anatomically prohibitive settings.MedChemExpress (MCE) offers a wide range of high-quality research chemicals and biochemicals (novel life-science reagents, reference compounds and natural compounds) for scientific use. We have professionally experienced and friendly staff to meet your needs. We are a competent and trustworthy partner for your research and scientific projects.Related websites: https://www.medchemexpress.com