Images and Case Reports in Interventional Cardiology Thrombotic Aortic Restenosis After Transapical Sapien Valve Implantation

A 78-year-old man at high risk for aortic valve replacement (Euroscore, 44%; left ventricular ejection fraction, 30%; previous bypass graft surgery) had undergone a transapical aortic valve implantation (26-mm Edwards Sapien) with a good immediate clinical and echocardiographic outcome: peak transvalvular gradient, 15 mm Hg; aortic valve area, 1.6 cm; and trivial aortic regurgitation (Figure 1). He was treated with dual-antiplatelet therapy (clopidogrel, 75 mg/d for 1 month; aspirin, 100 mg/d lifelong), as recommended after Sapien valve implantation. The clinical and echocardiographic follow-ups at 1 month were excellent (New York Heart Association class II; peak transvalvular gradient, 18 mm Hg; aortic valve area, 1.6 cm). The patient was admitted 4 months after the procedure to the emergency department with a non–ST segment elevation myocardial infarction, signs of left heart failure, and an aortic systolic murmur. There was no evidence of endocarditis: no fever, no rash, and normal inflammatory parameters as per laboratory findings. The coronary angiogram showed graft patency, and the aortic angiogram (Figure 2) demonstrated an asymmetrical opening of the Sapien valve leaflets, despite the circular shape and transannular position of the stent, and the absence of a significant aortic regurgitation (supplemental movie in the online-only Data Supplement). During cardiac catheterization, a ViewFlex catheter (St. Jude Medical) was introduced through the femoral vein to perform intracardiac