Excerpt

A 75-year-old female who underwent surgical aortic valve replacement with a 21-mm mosaic bioprosthetic valve (Medtronic, Dublin, Ireland) 8 years prior presented symptomatic severe bioprosthetic valve stenosis. She was deemed high risk for open aortic valve replacement (STS score 13.3%) and a transcatheter aortic valve replacement (TAVR) was considered. Because the patient had relatively large body surface area (1.85 cm²), even with a self-expandable valve, a prosthesis-patient mismatch was concerned. Thus, we planned a bioprosthetic valve fracturing as necessary. Due to the several risks of coronary obstruction (average diameter of sinuses of Valsalva was 27.7 cm, low coronary arteries, small virtual transcatheter heart valve-coronary distances, Fig. 1a, b), we planned coronary protection with a stent. In this situation, we thought that the balloon-expandable valve was preferable because the catheter manipulation would be easier when there was a necessity to deliver devices into the coronary other than the stent. Therefore, we planned valve-in-valve TAVR, possible valve fracturing, with a 23-mm Edwards Sapien 3 valve (S3, Edwards Lifesciences, CA, USA) with a coronary protection.

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