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- Self-expanding transcatheter aortic valve infolding: Current evidence, diagnosis, and management.Catheter Cardiovasc Interv. 2021; 98: E299-E305
Publication stageIn Press Journal Pre-Proof
No funding related to this report
Disclosure: S Noble is a proctor for Medtronic, the other authors have no conflict of interest
An 83-year-old gentleman underwent a TAVR using a 34-mm Evolut-R valve. Considering the mean gradient and the presence of the string sign, post-dilatation was performed. The infolding persisted on fluoroscopy but final mean gradient was 9 mmHg. At 30-day follow-up, TEE and CT scan showed a heart-shaped prosthesis inflow. Three-year follow-up did not show signs of early structural valve deterioration.
•A vertical line along the valve frame corresponds to an infolding of the frame and it is also known as the string sign
•Predisposing factors for frame infolding are resheathing (82%), improper valve loading (5%), type-1 bicuspid valve (11%), 29- or 34-mm Evolut, (94%) lack of predilatation (16%), severe calcification (65%) and oversizing. The last four factors being present in our case.
•The string sign may not be seen in the deployment projection (i.e. cusp overlap view)
•When the string sign is seen after valve deployment, cautious post-dilatation (being sure that the wire is still through the valve and not outside the infolded THV) should be performed in order to correct PVL