QAV accompanied by different hemodynamic abnormalities is usually treated with surgical valve repair or valve replacement with a synthetic valve. However, surgery may increase the incidence of valve thrombosis, prosthetic valve endocarditis, reduced valve durability, kidney injury, and bleeding complications.(3) Transcatheter valve implantation is now increasingly applied in clinical practice, which includes valve-in-valve treatment for failing bio-prostheses, low-risk patients, native pure aortic regurgitation, and for treatment of congenital valve disease such as bicuspid aortic valves with complex anatomical characteristics.(8) Nevertheless, due to the scarcity of QAV, the durability of prosthetic valve and long-term outcomes remain uncertain. To date, only a few cases of stenosed QAV treated successfully with transcatheter valve implantation have been reported. Unlike aortic stenosis, transcatheter valve implantation is not yet recommended in guidelines for treating pure aortic regurgitation. Some previous off-label clinical experiences showed that the rate of all-cause mortality using the first-generation transcatheter devices in treating pure aortic regurgitation at 30 days was up to 30%, as well as the high incidence of postoperative complications encompassing perivalvular leakage, residual aortic regurgitation, valve-in-valve procedures, fatal bleeding, major vascular damage, permanent pacemaker implantation, acute kidney injury, and stroke.(9, 10) Therefore, treatment and prognosis of QAV patients with aortic regurgitation are still challenging.
J-Valve with three “U-shape” graspers is a second-generation self-expandable device which has been approved for treating both aortic stenosis and aortic regurgitation in China. The unique structures of J-Valve system are effective for positioning, anchoring and protecting coronary arteries: (1) the three U-shape graspers are conductive to anchor the leaflets, which decreases the risk of perivalvular leakage and valve displacement; (2) the short path from the apex to the aortic annulus is helpful for adjusting the coaxiality and reducing major vascular damage; (3) because the fixation of J-Valve does not need a robust radial support force, it can be released at a lower level to reduce the rate of conduction block; (4) the low profile and bare metal area are designed for graspers to avoid coronary occlusion, especially for further coronary recanalization after primary valve replacement.(11)
Liu et al.(12) reported that a success rate of 97.7% and a mortality rate of 4.7% were observed in patients with pure aortic regurgitation treated by J-Valve. The rate of permanent pacemaker implantation was 4.7%, 2.3% patients suffered stroke, and the treatment for failing prostheses rate was 7.0%. During 1-year follow-up, only one patient had mild perivalvular leakage. Xue et al.(11) discovered that the success rate of J-Valve implantation was 91.3%, and the mortality was 4.3%. No cases underwent permanent pacemaker implantation and only one patient suffered mild stroke. No paravalvular leakage was observed during the follow-up. To sum up, the new-generation devices such as J-Valve had a higher device success and a significant reduction in postoperative complications compared to the old-generation.
It is worth noting that the angles among the adjacent graspers are 120°, whereas the angles of adjacent QAV leaflets are 90°. Considering the mismatching between the graspers and the leaflets, we carefully rotated the graspers during the procedure to ensure them capturing the leaflets instead of translocation. Second, valve positioning was fluoroscopically challenging. We folded the three “U-shape” graspers as three “long elliptical shape” under fluoroscopy, which was very helpful for positioning. Third, the position of the left main coronary ostia was relatively low, which needed to be prudently considered in case of coronary occlusion.