Low Risk Evolut CoreValve TAVR Explant: The Snow Cone Technique

V. Badhwar, A. Darehzereshki
West Virginia University, Morgantown, West Virginia

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Purpose: Transcatheter aortic valve replacement (TAVR) implantation has become a routine therapy at all levels of surgical risk. Surgical TAVR explantation is a rapidly growing procedure, particularly in low-risk patients, yet techniques to improve safety and outcomes are evolving. We present a technique to deal with self-expanding TAVR explantation.

Methods: The patient is a robust 79-year-old male who underwent 29 mm self-expanding TAVR (CoreValve Evolut, Medtronic, Minneapolis, MN) at an outside hospital in 2017 at age 72. His STS PROM was 1.2% at implantation as part of the Low Risk Evolut trial. His TAVR was complicated by a very low implantation and need for an immediate permanent pacemaker. He presents with a 12-month history of dyspnea and recent admission for heart failure that revealed structural valve degeneration (SVD) and severe prosthetic regurgitation without evidence of endocarditis. His recalculated STS PROM for TAVR explant and AVR was 1.4%. The normal skirt height of the prosthesis is 13 mm. Imaging revealed that the proximal 27 mm, or nearly half, of the prosthesis was subvalvular, involving the outflow tract and anterior mitral leaflet.

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Results: After heart-team and shared patient decision-making, informed consent included possible root replacement and possible reconstruction of the intervalvular fibrosa and mitral valve. The patient was approached via median sternotomy and planned bicaval cannulation. During retrograde cardioplegic induction, aortotomy was commenced at or slightly below the palpable distal TAVR prongs. The prosthesis was heavily endothelialized and incorporated into the aortic wall. The distal 10 mm of the prothesis was freed from the aorta via blunt endarterectomy techniques and a silk suture was used to purse string the prongs then brought through the flared end of a 32-French silastic chest tube to create a cone. This helped facilitated stepwise blunt dissection to endarterectomize the prosthesis to the native aortic valve. Once the main body was freed, the cone was retracted, and ice applied to cool the nitinol frame facilitating further sliding of the cone over the incorporated and collapsing prosthesis (Video). The valvular and subvalvular portion of the dissection was then safely performed and the TAVR explanted. The native trileaflet valve was removed and conventional AVR performed. The anterior aorta was denuded and required a small autologous pericardial patch to facilitate safe aortotomy closure. The patient was extubated and recovered.

Conclusions: As TAVR explantation is becoming a more common yet still complex operation, techniques to improve outcomes are needed. The described method might be one such option for surgeons to consider in their armamentarium when approaching the explant of self-expanding prostheses.