Transapical Implantation of a Melody Valve in a Degenerated Low-Diameter Prosthetic Aortic Valve

78-year-old woman had undergone a biological aortic valve replacement (Mitroflow Pericardial, Sorin Inc, Burnaby, BC, Canada) and coronary artery bypass graft surgery 8 years previously. Acute exacerbation of her symptoms resulting from prosthetic aortic valve stenosis caused respiratory failure, necessitating resuscitation and mechanical ventilation. A transthoracic Doppler echocardiogram demonstrated peak and mean prosthetic aortic valve gradients of 70 and 51 mm Hg, respectively, and a calculated valve area of 0.5cm 2 (Figure 1). Coronary angiography demonstrated triple-vessel disease and 3 patent grafts to all coronary territories. Although the need for a tracheostomy and the seeming adherence of patent grafts to the sternal plate precluded conventional surgical intervention, the prosthetic valve size of 19 mm deemed the patient unsuitable for a conventional transcatheter aortic valve implantation. A Melody valve (Medtronic Inc, Santa Ana, CA), because of its suitability for annular diameters of 16 to 22 mm, was a possible solution. A surgical transapical approach was chosen because of the limitations of the Melody transvenous delivery system, poor vascular access, and the need for absolute control during the procedure. A pediatric cardiologist (E.B.) familiar with the Melody system was integrated into the team. The valve delivery system, Ensemble, is a balloon-in-balloon over-the-wire catheter onto which the valve is hand crimped. The level of expansion of the valve is determined by the size of the outer balloon used for inflation (range, 18–22 mm). The balloon and Melody valve are covered by a movable sleeve that is retracted before positioning and deployment with 22F profile that could easily be advanced through a 24F Ascendra-2 transapical sheath (Ascendra Inc, Reston, VA) originally designed for Edwards-XT transcatheter aortic valve implantation with its radiopaque markers and a reliable hemostatic seal. The femoral vessels were accessed for transvenous pacing and an aortic root marker pigtail catheter. The working angle was determined to be perpendicular to the Mitroflow ring (Figures 2 and 3). To avoid unequal valve expansion and to verify the true inner diameter of Mitroflow, we predilated the stenotic valve with a Nucleus 18-mm balloon (NuMed Inc, Hopkington, NY; Figure 4). After the valvuloplasty, the Melody delivery system was introduced via the Ascendra-2 sheath and positioned in a 50:50 position through the valve