Corti, Roberto

Falk, Volkmar

Gebhard, Catherine

Jenni, Rolf

Stähli, Barbara E.

Tanner, Felix C.

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30. Tissot AC, Maurer P, Nussberger J, Sabat R, Pfister T, Ignatenko S, Volk HD,Stocker H, Muller P, Jennings GT, Wagner F, Bachmann MF. Effect of immunisationagainst angiotensin II with CYT006-AngQb on ambulatory blood pressure: adouble-blind, randomised, placebo-controlled phase IIa study. Lancet 2008;371:821–827.31. Weber MA, Black H, Bakris G, Krum H, Linas S, Weiss R, Linseman JV, Wiens BL,Warren MS, Lindholm LH. A selective endothelin-receptor antagonist to reduceblood pressure in patients with treatment-resistant hypertension: a randomised,double-blind, placebo-controlled trial. Lancet 2009;374:1423–1431.32. Bhatt DL. Advancing the care of cardiac patients using registry data: going whererandomized clinical trials dare not. JAMA 2010;303:2188–2189.33. Kumbhani DJ, Steg PG, Cannon CP, Eagle KA, Smith SC Jr, Crowley K, Goto S,Ohman EM, Bhatt DL. 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Task force IV: Clinical use ofambulatory blood pressure monitoring. Participants of the 1999 Consensus Con-ference on Ambulatory Blood Pressure Monitoring. Blood Press Monit 1999;4:319–331.CARDIOVASCULAR FLASHLIGHT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/ehs307Online publish-ahead-of-print 17 September 2012Regurgitation after Edwards SAPIEN valve implantation: truly paravalvularor ‘supra-skirtal’?Barbara E. Sta¨hli1, Catherine Gebhard1, Volkmar Falk2, Roberto Corti1, Rolf Jenni1, and Felix C. Tanner1*1Department of Cardiology, Cardiovascular Center, University Hospital Zu¨rich, Ra¨mistrasse 100, 8091, Zu¨rich, Switzerland and 2Clinic for Cardiovascular Surgery,Cardiovascular Center, University Hospital Zu¨rich, Ra¨mistrasse 100, 8091, Zu¨rich, Switzerland* Corresponding author. Tel: +41 44 255 99 97, Fax: +41 44 255 48 04, Email: felix.tanner@access.uzh.chThis paper was guest edited by Frank Rademakers, University Hospital Gasthuisberg, Leuven, BelgiumA 73-year-old male was referred with severe mitralregurgitation 9 years after mitral valve annuloplastywith a 32-mm Edwards Lifesciences ring. On thebasis of an anticipated high perioperative riskrelated to chronic kidney disease and left ventricularsystolic dysfunction, mitral valve-in-ring implant-ation using a 29-mm Edwards SAPIEN prosthesiswas performed by transapical access (Panel A). Post-procedural three-dimensional transoesophagealechocardiography revealed three paravalvular re-gurgitation jets at the 3, 7, and the 11 o’clock posi-tions (Panels B and C ).In this patient, we observed a third type of regur-gitation in Edwards SAPIEN prostheses, which iscaused by the device design. Edwards SAPIEN pros-theses are built up by bovine pericardial tissue leaf-lets fixed on a stainless steel frame. A polyethyleneterephthalate skirt partially covers the steel frame.However, since the skirt covers the basal two-thirdsof the frame only, regurgitation through its uncov-ered part may occur (arrow, Panel D; adaptedfrom www.edwards.com/products/transcathetervalve/Pages/sapienthv.aspx). This type of regurgitation was seen in the patient presented here, since the skirt is positioned in the leftatrium rather than the annuloplasty ring. The commissures cover the whole length of the steel frame, and the regurgitation jetsare therefore located in between the commissures and positioned 1208 apart from each other. In patients with EdwardsSAPIEN prostheses in aortic position, the same phenomenon may be observed with prostheses implanted too apically. However,as the left ventricular outflow tract is narrow, regurgitation jets are more difficult to visualize.Hence, after Edwards SAPIEN prosthesis implantation, regurgitation is transvalvular or paravalvular or ‘supra-skirtal’. As the tech-nology of transcatheter valves is still evolving, constant improvement in the device design and proper placement of the prosthesis areimportant.Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2012. For permissions please email: journals.permissions@oup.comD.J. Kumbhani et al.1214

Regurgitation after Edwards SAPIEN valve implantation: truly paravalvular or ‘supra-skirtal'?

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