Previously implanted mitral surgical prosthesis in patients undergoing transcatheter aortic valve implantation: Procedural outcome and morphologic assessment using multidetector computed tomography

Abstract

Transcatheter aortic valve implantation (TAVI) in the presence of a preexisting mitral prosthesis is challenging and its influence on the morphology of mitral prosthesis and the positioning of transcatheter heart valve (THV) is unknown. We assessed the feasibility of TAVI for patients with preexisting mitral prostheses, its influence on mitral prosthesis morphology, and the positional interaction between a newly implanted THV and mitral prosthesis using serial multidetector computed tomography (MDCT). Thirty-one patients with preexisting mitral prosthesis undergoing TAVI were included. MDCT was performed before and after TAVI. Thirty patients successfully underwent TAVI without interference from preexisting mitral prosthesis. Although opening disturbance of the mechanical mitral prosthesis by the THV edge was observed in 1 patient, the patient was managed conservatively. No THV embolization occurred. THV shift during deployment occurred in 9 patients and was predicted by a larger aortic annulus area (odds ratio: 1.24 per 10 mm2, 1.03–1.49, p = 0.02), possibly because of large THVs. The mitral mean pressure gradient was slightly higher after TAVI (3.7 vs. 4.3 mmHg, p = 0.002), whereas the mitral regurgitation grade was similar. MDCT showed that the size of the mitral prosthesis housing was unchanged after TAVI. The median distance between the mitral prosthesis and THV was 2.6 mm. The postprocedural angle between the mitral prosthesis and THV was larger than the preprocedural angle between the mitral prosthesis and the left ventricular outflow tract (64° vs. 61°, p = 0.03). Thus, TAVI is feasible in the case of preexisting mitral prosthesis. Serial MDCT demonstrated favorable THV positioning and unchanged mitral prosthesis morphology after TAVI.

Patient‐specific computer simulation of transcatheter aortic valve replacement in patients with previous mechanical mitral prosthesis: A case series

“…Nevertheless, it remains an intervention with potential catastrophic complications, including device embolization or malposition, mainly due to the migration of the aortic prosthesis during implantation 10 . THV migration is associated with large native aortic annulus, 11 low calcific burden and predominant aortic regurgitation. The risk of aortic THV under‐expansion and the MMP dysfunction is related to the interaction between the prosthesis stent frame and the distal edge of the THV.…”

Safety of Transcatheter Aortic Valve Replacement in Patients with Prosthetic Mitral Valve

“…Mean THV pressure gradient immediately and 6 months after TAVR was slightly higher in patients with prior MVR (12.86 mmHg and 13.54 mmHg) than without prior MVR (11.23 mmHg and 10.53 mmHg) though statistically not significant (p = 0.144 and p = 0.062). 12) Tanaka et al reported that the incidence of THV stenosis was 6.5% and grade 3 or 4 PVL was 3.2% among 31 patients with prior MVR, respectively. 12) In recent prospective trials, grade 3 or 4 PVL has been improved to 2% to 3% simply due to newer TAVR devices.…”

“…12) Tanaka et al reported that the incidence of THV stenosis was 6.5% and grade 3 or 4 PVL was 3.2% among 31 patients with prior MVR, respectively. 12) In recent prospective trials, grade 3 or 4 PVL has been improved to 2% to 3% simply due to newer TAVR devices. 7)…”

“…11) In Japanese Ocean TAVI registry of 3043 patients, 31 (1.0%) had previously undergone MVR prior to TAVR, and no THV embolization occurred. 12) However, THV shift occurred in nine patients (29.0%; 8 for upward and 1 for downward direction) in SAPIEN (Edwards Lifesciences, Irvine, CA, USA) THV implantation. Largesized THV (26 or 29 mm) was a predictor of THV shift.…”

“…TAVR also has interference to a bileaflet mechanical mitral valve. 12) There was one patient who had ATS bileaflet valve (ATS Medical, Inc., Minneapolis, MN, USA) 29 mm in the mitral position. After a 23-mm SAPIEN 3 was implanted by transfemoral approach, the edge of SAPIEN 3 partially occluded the opening of one leaflet of the ATS valve.…”