Successful percutaneous paravalvular leak closure followed by transfemoral aortic lotus valve-in-valve implantation in a degenerated surgical bioprosthesis.

Bioprosthesis degeneration is a relevant clinical issue that is increasingly developing with the higher expectancy of life. Its treatment may be further complicated by the presence of paravalvular leaks, which are usually consequence of tissue friability, annular calcification, and infection. The surgical treatment of such complex conditions may be too risky, so percutaneous techniques in selected centers are becoming an attracting option. We report the case of a 65-year-old gentleman with a previous aortic valve replacement (Perimount n.25) who was admitted with worsening heart failure and transoesophageal evidence of severe intraprosthetic regurgitation and a large paravalvular leak. Since he was judged at too high risk for surgery, he was treated by a fully percutaneous approach. First, he had his large paravalvular leak closed by implantation of two plugs from both retrograde and anterograde routes (arterial-venous loop created). After one month, he underwent a "valve-in-valve" transcatheter aortic valve implantation with a fully repositionable Lotus 23 mm valve, which was able to restore a completely normal aortic valve function and let to a dramatic improvement of his functional status at 6-month follow-up (from NYHA IV to NYHA I), when a transthoracic echocardiogram also confirmed the absence of any aortic regurgitation. This case shows how a tailored step-by-step fully percutaneous strategy is safe and feasible in high-risk patients with both bioprosthesis degeneration and large paravalvular leaks. This novel opportunity would need to be better evaluated in properly addressed long-term clinical studies. © 2016 Wiley Periodicals, Inc.