For transcaval access, femoral venous and arterial access are required for snaring to create the inferior vena cava (IVC) to aorta wire access. With a low risk of catastrophic events during the procedure, general anesthesia is not mandatory. In a recent report of 75 patients undergoing VIV TAVR, there were no cases of coronary occlusion, annular rupture or need for permanent pacemaker insertion ( 1). The joint cardiac surgery and interventional cardiology heart valve team recommended a valve-in-valve transcatheter AV replacement (VIV TAVR) using bioprosthetic valve fracture (BVF) and transcaval access. The valve to right coronary artery distance was 9 mm and valve to left main coronary artery distance was 14.4 mm. Computerized tomography (CT) revealed a “porcelain aorta” with poor femoral access vessels (4.2 mm right external iliac artery, 5.2 mm left common iliac artery). Resting mean AV gradient was 30 mmHg, which increased to 44 mmHg with dobutamine stress echocardiography.

An echocardiogram revealed an ejection fraction of 50%, with an AV area of 0.8 cm 2. A Society of Thoracic Surgery (STS) score for redo AV replacement was 9.7%. Clinical vignetteĪ 71-year-old female with prior single vessel coronary artery bypass (left internal mammary artery to left anterior descending artery) and aortic valve (AV) replacement (21 mm Magna Model 3000, Edwards Lifesciences, Irvine, CA), presented with dyspnea.

Video Fracture of a 21 mm failed bioprosthetic aortic valve.

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