Surgical explantation of an infected Lotus Edge valve: a case report

Background: With the rapid expansion of transcatheter aortic valve replacement (TAVR), TAVR valve explantation is also increasing. Nevertheless, previous reports on Lotus Edge valve explantation are limited to only two reports, none of which include intraoperative videos. Therefore, we report the case of an older adult who underwent a 2-year-old Lotus Edge valve explantation, after developing prosthetic valve endocarditis (PVE) and aortic annular abscess, with a strong indication for a TAVR explantation and surgical aortic valve replacement (AVR).

Case presentation: An 85-year-old male patient, who underwent TAVR with a 25-mm Lotus Edge valve for severe aortic stenosis 2 years ago, was referred to our hospital. He presented with a 1-month history of high-grade fever, refractory to oral antimicrobials and trifascicular heart block. Two sets of blood cultures were positive for Streptococcus dysgalactiae subspecies equisimilis, and transesophageal echocardiography revealed vegetation on the valve leaflets. Enhanced computed tomography scan showed thickening and enhancement of the aortic root and aorto-mitral continuity, with a small low-density area. Therefore, we diagnosed PVE. Subsequently, we planned AVR re-intervention and pacemaker implantation. The vegetation mass was attached to the aortic valve leaflet. We attempted to explant the valve while deforming it using forceps. The areas with abscess formation were easily dissected; however, the other areas were difficult to separate. Cold-saline irrigation softened the nitinol stent and enabled to dissect the prosthetic valve from the aortic wall. The infected aortic annulus was irrigated and then repaired. AVR using a 21-mm Avalus bioprosthetic valve and epicardial pacemaker lead implantation were simultaneously performed. Postoperative echocardiography confirmed that the prosthetic valve function was favorable, and the patient was transferred to a rehabilitation hospital after 6 weeks of intravenous antimicrobial therapy.

Conclusion: The Lotus Edge valve is difficult to remove due to its fixation after deployment and strong adhesion, but the use of cold water may be effective in facilitating its removal.