Evolut R implantation in Perceval bioprosthesis with periprosthetic leakage. How would I approach it?

HOW WOULD I APPROACH IT? The authors hereby present the clinical case of an 80-year old male with symptomatic severe aortic stenosis, preserved ventricular function, mild mitral regurgitation and no coronary heart disease. He had low surgical risk (3.1% score in the Society of Thoracic Surgeons risk scale) and, in medical-surgical session, it was decided to proceed with a surgical aortic valvular replacement using the Perceval Sutureless Aortic Heart Valve, Sorin – size L. The follow-up echocardiogram prior to the patient’s discharge showed lack of sig- nificant aortic transvalvular gradient and periprosthetic regurgitation jets indicative of mild-to-moderate aortic regurgitation. Five months after the implantation of the valve, the patient was admitted to the hospital due to acute pulmonary edema. The echocardiogram showed severe aortic regurgitation due to the lack of stent coverage of the aortic bioprosthesis at the level of the aortic annulus and in the area of the non-coronary sinus and most of the right coronary sinus with two regurgitation jets towards the left dilated ventricle. The left ventricular ejection fraction was slightly depressed. Before considering any therapeutic approaches in a patient with aortic regurgitation following a valvular implantation there are 3 fundamental issues we should all be aware of: 1)...