Transcatheter aortic valve replacement in patients with previous mitral valve replacement. A systematic study

Abstract

Introduction: Severe aortic stenosis (AS) is an ever-growing healthcare problem in ageing populations. Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of AS. However, TAVI in patients who have undergone mitral valve replacement (MVR) is associated with increased risk of mitral valve damage. Limited data exist on TAVI in patients with AS who underwent MVR in the past. Aim: To retrospectively assess the clinical characteristics, detailed echocardiographic and computed tomography measurements, procedural and in-hospital outcome as well as any valve intervention or major adverse cardiovascular events according to VARC-2 criteria at follow-up of patients with a history of MVR, who underwent TAVI. Material and methods: Seventeen patients with a history of mitral valve operation, in whom TAVI was performed between 2010 and 2018, were identified. Of these, 15 underwent previous MVR. Results: Overall, TAVI resulted in a decrease of mean transaortic gradient by 38.3 ±14 mm Hg (p < 0.001) and a decrease of maximal transaortic gradient by 58.6 ±27.6 mm Hg (p < 0.001). A successful immediate result was obtained in 14 (93.3%) patients. One tamponade occurred during TAVI, which was successfully treated with pericardiocentesis. Post-procedurally, no significant changes in transmitral gradients or mitral regurgitations were observed. Two patients died after hospital discharge, one due to possible internal bleeding and the other due to infection. Conclusions: TAVI in patients after MVR is feasible. Meticulous preinterventional echocardiographic and computed tomography planning is essential. Although recommended in previous reports, TEE guidance may not necessarily be obligatory during the procedure.

Transcatheter aortic valve replacement in patients with a pre-existing prosthetic mitral valve: a single center experience with two cases

“…Furthermore, all cases of embolization occurred in subjects with the PMV to aortic annulus distance of < 7 mm by CT imaging. A minimum mitral-aortic distance of 3 mm for the balloon expandable Sapien valve and 4 mm for the self-expandable CoreValve has been recommended [ 8 ]. The two index cases had a distance of 6.3 mm and 3.6 mm, respectively, which are within the acceptable minimum range.…”

“…The preferential use of self-expandable valves in post-MVR TAVR procedures may seem logical in view of the possibility of partially recapturing the prostheses during deployment. However, recent reports and retrospective analyses have demonstrated similar peri-procedural outcomes with the use of either self or balloon expandable valves [ 8 , 9 , 15 ].…”

“…Patients who have undergone previous mitral valve replacement (MVR) represent a subset that has largely been excluded from trials demonstrating clinical and survival benefit of TAVR [ 1 – 3 ]. Existing data on the post-MVR TAVR procedure are limited to case reports/series [ 4 – 7 ] and retrospective analyses [ 8 – 11 ]. This explains why current guidelines have no specific recommendations for this subpopulation.…”

Percutaneous Treatment of Severe Aortic Regurgitation After Surgical Mitral Valve Repair

“…Transcatheter aortic valve implantation in patients with prior mitral valve interventions (ring or prosthesis) usually carries an additional specific risk of device interaction with the mitral structure, which sometimes is only partially predictable. 5 , 9 , 10 In particular, an increased risk of THV embolization and increased trans-mitral gradients have been reported, especially in patients with mechanical mitral prosthesis and a distance between the aortic annulus and the mitral prosthesis <7 mm. 5 In this specific patient, the estimated risk for valve embolization was very low because of the unique leaflet-anchoring mechanism of the selected THV; the major concern was regarding the possible interaction of the mitral ring with the metallic LVOT frame of the THV that could potentially be responsible for frame deformation and paravalvular regurgitation.…”

Redo aortic valve replacement vs valve-in-valve trans-catheter aortic valve implantation: a UK propensity-matched analysis

“…Redo cardiac surgery in patients with severe aortic stenosis and/or prosthetic valve dysfunction carries a mortality rate of 5-26% [7][8][9]; hence a lower risk less-invasive percutaneous approach seems appealing. Nevertheless, patients with previous cardiac surgery have often been excluded from consideration of TAVI, because of the risk of prosthetic displacement and coronary grafts occlusion [7,[10][11][12].…”