Although percutaneous aortic valve replacement (PAVR) has been used to treat severe aortic stenosis for high-risk surgical patients not suitable for conventional surgery, the feasibility of using PAVR for treatment of severe paravalvular regurgitation in patients with prior aortic valve replacement is unknown. We would like to share our experience with an 82-year-old man referred for PAVR for treatment of grade 3 paravalvular aortic regurgitation with a “valve-in-valve” procedure. With a background history of aortic valve replacement (Medtronic Freestyle stentless aortic valve, 23 mm; Medtronic Inc., Minneapolis, Minnesota) and coronary artery bypass surgery 11 years previous, New York Heart Association functional class III heart failure with a biventricular pacemaker in-situ, hypertension, diabetes mellitus, and previous transient ischemic attacks, the patient's logistic Euroscore was 28%. Pre-operative transesophageal echocardiogram (TEE) showed severe paravalvular leak ((Figure 1)A,Online Video 1), and cardiac computed tomography showed a direct paravalvular communication between the aortic root and left ventricular outflow tract (Figure 1B).

A 26-mm Edwards-Sapien percutaneous bioprosthetic valve (Edwards Lifesciences, Inc., Irvine, California) was implanted with the transapical approach, under fluoroscopic and TEE guidance. The PAVR was implanted, to occlude the paravalvular leak, in the left ventricular outflow tract, inferior to the original valve replacement in a valve-in-valve procedure. However, TEE showed increased aortic regurgitation severity due to nondeployment of a single prosthetic aortic cusp ((Figure 1)C, Online Videos 2 and 3). A second 26-mm Edwards-Sapien percutaneous bioprosthetic valve was implanted in-between the 2 previous valves ((Figure 1)D, Online Video 4). Final TEE showed a good result with minimal residual paravalvular leak and mild central aortic regurgitation ((Figure 1)E, Online Video 5). The patient was followed-up at 1 month, and repeat transthoracic echocardiogram and cardiac computed tomography showed excellent percutaneous bioprosthetic valve deployment (Figure 1F). This case illustrated the feasibility of using a valve-in-valve PAVR procedure for treatment of severe paravalvular aortic regurgitation.

For accompanying videos, please see the online version of this article.