title: Significant transaortic gradient after direct flow aortic valve implantation.
abstract: A patient with severe aortic valve disease and high surgical risk underwent Direct Flow (DF) valve implantation. Anatomical assessment (Trans-esophageal echocardiography (TEE) and CT scan) revealed a 3-leaflet aortic valve (annulus diameter 23.4 mm) that was functionally bicuspid because of complete and linearly calcified fusion of noncoronary and right cusps. The valve had severe stenosis (peak/mean gradients of 70/45 mm Hg) and moderate to severe regurgitation. A balloon valvuloplasty (semicompliant 23 mm × 45 mm balloon, 2 inflations) was performed with persistence of balloon waist. A 25 DF valve was positioned in the aortic annulus, with both rings well expanded. A mild deformity in the vertical supporting tubes was observed but considered nonrelevant because valve function (peak/mean gradients of 25/12 mm Hg respectively and no aortic regurgitation) was acceptable. Then the polymer was injected and the valve released from its attachments. Postoperative course was uneventful without clinical complications; nevertheless 3 days later Doppler peak/mean transaortic gradients were 80/45 mm Hg. These high gradients were confirmed by direct invasive measurements while CT scan documented a severe geometrical deformation of the valve cuff. Since patient was in good clinical condition, a conservative strategy was adopted. Eight months later, patient functional status had improved (NYHA class II), left ventricular dimensions decreased, left ventricular ejection fraction (LVEF) increased, and valve gradients remained unchanged; therefore surgical aortic valve replacement has been deferred until clinical indication. Such a favorable course can be explained by disappearance of aortic regurgitation. Patient anatomical and procedural features that conditioned this very rare phenomenon are discussed as well as clues to prevent it.
authors.affiliation: Cardiology Department, Hospital Ramón Y Cajal, Madrid, Spain.
authors.forename: Rosa-Ana
authors.initials: RA
authors.lastname: Hernandez-Antolín
authors.affiliation: Cardiology Department, Hospital Ramón Y Cajal, Madrid, Spain.
authors.forename: Luisa
authors.initials: L
authors.lastname: Salido
authors.affiliation: Cardiology Department, Hospital Ramón Y Cajal, Madrid, Spain.
authors.forename: José Luis
authors.initials: JL
authors.lastname: Zamorano
mesh_terms: D000368:Aged; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000503:physiopathology*; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D063126:Balloon Valvuloplasty; D006328:Cardiac Catheterization / Q000295:instrumentation* / Q000379:methods; D015150:Echocardiography, Doppler; D017548:Echocardiography, Transesophageal; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000295:instrumentation* / Q000379:methods; D006439:Hemodynamics; D006801:Humans; D008297:Male; D011474:Prosthesis Design; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
keywords: aortic stenosis; geometrical deformation; mismatch; percutaneous; radial force