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Year : 2022  |  Volume : 32  |  Issue : 3  |  Page : 168-171

Aortic biological prosthetic valve dysfunction secondary to endocarditis: Is percutaneous valve-in-valve an option?

Division of Cardiology, A.O.U. Policlinico “G. Rodolico - San Marco”, Catania, Italy

Date of Submission16-Mar-2022
Date of Acceptance17-May-2022
Date of Web Publication16-Nov-2022

Correspondence Address:
Paolo Zappulla
Division of Cardiology, A.O.U. Policlinico “G. Rodolico - San Marco”, Via Santa Sofia N 78, Catania
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcecho.jcecho_15_22

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We present the case of a 69-year-old man with an aortic biological prosthetic valve. In May 2019, the patient experienced increasing dyspnea and fatigue: A diagnosis of prosthetic aortic valve dysfunction was made, leading to severe valvular insufficiency. The dysfunction of the prosthetic valve seemed to be linked to a previous infective endocarditis: after ruling out active endocarditis, the patient was treated with an off-label valve-in-valve transcatheter aortic valve implantation.

Keywords: Aortic biological prosthetic valve dysfunction, endocarditis, valve-in-valve transcatheter aortic valve implantation

How to cite this article:
Giuseppe B, Deste W, Zappulla P, Passaniti G, Barbanti M, Criscione E, Sgroi C, Tamburino C. Aortic biological prosthetic valve dysfunction secondary to endocarditis: Is percutaneous valve-in-valve an option?. J Cardiovasc Echography 2022;32:168-71

How to cite this URL:
Giuseppe B, Deste W, Zappulla P, Passaniti G, Barbanti M, Criscione E, Sgroi C, Tamburino C. Aortic biological prosthetic valve dysfunction secondary to endocarditis: Is percutaneous valve-in-valve an option?. J Cardiovasc Echography [serial online] 2022 [cited 2023 Apr 1];32:168-71. Available from: https://www.jcecho.org/text.asp?2022/32/3/168/361209

  Introduction Top

Infective endocarditis affects almost 1%–6% of the patients with a prosthetic aortic valve, with an incidence of 0.3%–1.2% per patient/year[1],[2] and represents one of the most important causes of prosthesis dysfunction in these patients.

According to the latest ESC endocarditis' guidelines,[3] surgical prosthesis replacement should be performed in cases of heart failure, pulmonary edema or cardiogenic shock, uncontrolled infection or in cases of persistent vegetations bigger than 1 cm, to prevent cases of embolism. Surgical replacement carries a rate of in-hospital mortality of 4%, 6% for elective procedures, and 17% for urgent/emergent procedures. Actually, guidelines consider only surgical replacement and not percutaneous Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI), due to the high infectious and embolic risks linked with this approach.[4],[5] But can ViV-TAVI be considered as a treatment option in a patient with high surgical risk and prosthetic aortic dysfunction after a previous infectious endocarditis, no more active?

  Case Report Top

We present the case of a 69-year-old man with a biological prosthetic aortic valve dysfunction in a Bentall graft, caused by a previous infective endocarditis, treated with percutaneous ViV TAVI.

The patient had a medical history of chronic hypertension, dyslipidemia, persistent atrial fibrillation, and chronic obstructive pulmonary disease. In 2004, he underwent aortic root and valve replacement with a Bentall technique, receiving a biological aortic Hancock 25 mm prosthesis.

In May 2019, he was admitted to our department for chest pain after mild effort Canadian Cardiovascular Society Grading of Angina (CCS III). Coronary angiography was performed and showed no coronary artery disease. Transthoracic echocardiography showed severe aortic valve regurgitation in a mild dilated left ventricle, without segmental wall motion abnormalities (ejection fraction [EF] 55%, EDD 60 mm, end-diastolic volume 185 ml, Gmax 74 mmHg, Gmed 43 mmHg, Pressure Half Time (PHT) 183 m/s, and systolic pulmonary artery pressure [sPAP] 44 mmHg).

Considering the strong suspicion of infective endocarditis, a transesophageal echocardiogram was carried out and showed a valvular dysfunction and two little nodular growths on the noncoronaric and the left-coronary prosthetic leaflets, demonstrating intraprosthetic regurgitation, and no periprosthetic leak [Figure 1], [Figure 2], [Figure 3].
Figure 1: Aortic regurgitation evaluated with TOE before the percutaneous treatment. TOE = Transesophageal echocardiogram

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Figure 2: Aortic regurgitation evaluated with TOE before the percutaneous treatment. X-Plane view. TOE = Transesophageal echocardiogram

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Figure 3: Nodular growths on the noncoronaric and the left coronaric prosthethic aortic leaflets

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Hence, he was transferred to the department of infectious diseases, where various diagnostic procedures were carried out:

  • Blood chemistry test, resulting in the absence of inflammation signs (no elevation of C-reactive protein and Procalcitonin, no leukocytosis, and beta-D-glucan was not detected)
  • Three sets of blood cultures, each with three blood samples, all resulted negative
  • Research of Ab-Anti-Mycoplasma immunoglobulin M, Ab-Anti-Chlamydia, Ab-Anti-Borrelia, Ab-Anti-Rickettsia, to exclude blood culture-negative endocarditis, all resulted negative
  • Continuous clinical monitoring, with no evidence of fever
  • Thoracic computed tomography (CT) scan that revealed chronic pulmonary emphysema, widespread ground-glass pattern, with no evidence of flogistic areas.

In July 2019, he was admitted to our department with heart failure and severe aortic regurgitation. The heart team evaluated the best strategy for prosthetic aortic replacement, between surgical or percutaneous. Considering patient's Surgical scores: STS mortality score 1,29; STS mortality-morbidity score 11,3; Logistic EuroSCORE 12,1; and new EuroSCORE II 9, 5, the cardiothoracic surgeon and anesthesiologist did not approve surgical procedure, so the only option left was to perform a percutaneous, off-label, and ViV TAVI.

In addition, the patient underwent a thoracic angio-CT, to acquire more information about the valvular and aortic root prosthesis status and measures before the procedure and, at the end of July 2019, we performed the scheduled transfemoral ViV-TAVI, implanting an Edwards SAPIEN Ultra 23 mm valve. The procedure was performed in deep sedation, with a transesophageal echocardiography guide, to achieve the best prosthesis setting, with the minimum para-and intra-prosthetic leakage. We also utilized the “Sentinel Cerebral protection System,” introduced through right radial artery, for prevention of any embolic complications.

A postprocedure transthoracic echocardiography was performed, resulting in a well-seated prosthesis without any paravalvular leak or intra-prosthetic regurgitation and with no evidence of pericardial effusion [Figure 4]. During the whole hospitalization, the patient did not present any adverse event concerning major or minor bleeding, atrioventricular block, or feverish episodes and was discharged after 4 days-recovery. In August 2019, we performed the 1-month postoperative follow-up, resulting in a good left ventricle EF (EF 58%, EDD 60 mm), good prosthesis positioning and functioning, without leakages, with a remaining mild aortic stenosis (Gmax 44 mmHg, Gmed 23 mmHg), absence of pericardial effusion, sPAP 35 mmHg [Figure 5] and [Figure 6]. He did not report any cardiac symptoms. In January 2020, we performed the 6-month follow-up, confirming the mild aortic stenosis (Gmax 38 mmHg, Gmed 21 mmHg), EF 60%, and sPAP 20 mmHg, with striking improvement of his overall clinical condition. He is still will under close follow-up.
Figure 4: Postprocedural parasternal short axis view at aortic valve level showing a well seated and functioning valve with no para- or intra-prosthetic leaks

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Figure 5: Apical four-chamber view at 1-month follow-up showing no residual aortic regurgitation

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Figure 6: Apical three-chamber view at 1-month follow-up

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  Discussion Top

Surgical prosthetic valve replacement is the gold standard for the management of prosthetic valve dysfunction; according to the latest guidelines, percutaneous treatment is not indicated as a treatment option.

The surgical replacement of a prosthetic valve is associated with a significant risk of early morbidity and mortality.[6] Nevertheless, the increased experience and excellent outcomes seen with TAVI for the management of severe aortic stenosis ensure this technique in cases of bioprosthesis aortic dysfunction in high-risk patients, assuring great clinical outcomes in terms of low rates of mortality and major complications, improvement of symptoms, New York Heart Association functional capacity, and quality of life at 30 days, 1 year, and 3 years.[7],[8],[9]

Our patient was considered at high-risk for surgery but suitable for percutaneous ViV-TAVI. To prevent embolism, we used the SENTINEL Cerebral Protection System during the procedure and, to prevent periprosthesic leakage, we did a transesophageal echocardiogram-guided procedure.

The evolution of technology, accumulation of experience with large bore access, and the increased risk associated with valve replacement in patients following a previous sternotomy has led to the emerging need of the treatment of bioprosthetic valve degeneration with ViV procedures.[10]

This case demonstrates the ViV-TAVI security and efficacy for selected patients with degenerative prosthetic aortic valve disease, despite a history of infective endocarditis.

Currently, there are limited data on the long-term durability of this approach. Future studies may show that in high surgical risk patients with a degenerated bioprosthetic aortic valves and a history of infective endocarditis, ViV TAVR may be an alternative procedure to redo surgery.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Vincent LL, Otto CM. Infective endocarditis: Update on epidemiology, outcomes, and management. Curr Cardiol Rep 2018;20:86.  Back to cited text no. 1
Wang A, Gaca JG, Chu VH. Management considerations in infective endocarditis: A review. JAMA 2018;320:72-83.  Back to cited text no. 2
Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta JP, Del Zotti F, et al. ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Heart J 2015;36:3075-128.  Back to cited text no. 3
Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, Baumgartner H, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2012;42:S1-44.  Back to cited text no. 4
Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. 2017 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2017;38:2739-91.  Back to cited text no. 5
Van Vlasselaer A, Rasmussen M, Nilsson J, Olaison L, Ragnarsson S. Native aortic versus mitral valve infective endocarditis: A nationwide registry study. Open Heart 2019;6:e000926.  Back to cited text no. 6
Sawaya FJ, Deutsch MA, Seiffert M, Yoon SH, Codner P, Wickramarachchi U, et al. Safety and efficacy of transcatheter aortic valve replacement in the treatment of pure aortic regurgitation in native valves and failing surgical bioprostheses: Results from an International Registry Study. JACC Cardiovasc Interv 2017;10:1048-56.  Back to cited text no. 7
Webb JG, Mack MJ, White JM, Dvir D, Blanke P, Herrmann HC, et al. Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: PARTNER 2 Valve-in-Valve Registry. J Am Coll Cardiol 2017;69:2253-62.  Back to cited text no. 8
Webb JG, Murdoch DJ, Alu MC, Cheung A, Crowley A, Dvir D, et al. 3-year outcomes after valve-in-valve transcatheter aortic valve replacement for degenerated bioprostheses: The PARTNER 2 Registry. J Am Coll Cardiol 2019;73:2647-55.  Back to cited text no. 9
Goldstone AB, Chiu P, Baiocchi M, Lingala B, Patrick WL, Fischbein MP, et al. Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement. N Engl J Med 2017;377:1847-57.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]


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