Transfemoral Aortic Valve Implantation With Pre-Existent Mechanical Mitral Prosthesis

Abstract

An 82-year-old woman was referred to our institution for treatment of a severe aortic stenosis (valve area 0.5 cm 2 , mean aortic gradient 45 mm Hg, left ventricular ejection fraction 45%) because of recent pulmonary edema.She had a history of hypertension, atrial fibrillation, and transient ischemic attack. Twenty-five years ago, she underwent a mitral valve replacement with a Lillehei-Kaster prosthesis. Angiocoronarography showed no significant coronary artery disease.The risk of operative mortality for conventional surgery was 26.5% according to the Society of Thoracic Surgeons Score. The patient was considered as a high-surgical-risk candidate, and she was evaluated for transcatheter aortic valve implantation (TAVI).Aortic annulus assessed by transesophageal echocardiography (TEE) was 21 mm. Femoral and iliac arteries evaluated by angiography and multislice computed tomography were straight with internal diameters Ͼ8 mm and mild calcifications. The TAVI by a transfemoral approach with a 23 mm balloon-expandable valve was planned.Several concerns raised before the procedure include the following: 1) the possibility of underexpansion of the aortic prosthesis in relation to the noncompliant mechanical mitral prosthesis close to the aortic annulus (the distance measured by TEE between aortic annulus and mechanical mitral prosthesis was 9.7 mm) (Fig. 1A); 2) the risk of embolization of the device caused by a kind of "watermelon seeding" effect; and 3) the risk of postoperative dysfunction of the mitral prosthesis in case of conflict between its pivoting disc and the distal edge of the aortic prosthesis.The procedure was performed under general anesthesia, fluoroscopy, and TEE guidance. Balloon aortic valvuloplasty with a 23-mm balloon showed a good expansion and stability of the balloon and no conflict with the mitral prosthesis (Fig. 1B, Online Video 1). A 23-mm Edwards Sapien valve (Edwards Lifesciences, Inc., Irvine, California) was then implanted (Online Video 2). Immediate fluoroscopic and TEE control showed normal mitral and aortic prosthesis functions with only grade 1 aortic paravalvular leak (Figs. 1C and 1D, Online Video 3). The patient was discharged 7 days after the procedure without any complications.At 1-month follow-up, she was in New York Heart Association functional class II. Transthoracic echocardiography showed a correct position and function of the aortic and mitral valves.A TAVI with a transapical approach with a balloon-expandable aortic valve, in a patient with mechanical mitral valve prosthesis, has recently been reported (1). This case demonstrates the feasibility of a transfemoral approach in such a situation.

Trans-catheter Aortic Valve Implantation in Patients with Previous Mitral Valve Replacement: A Case Series

“…The risk of post-procedural dysfunction of the mitral prosthesis as a consequence of its damage during percutaneous manipulation or due to functional interference with aortic bioprosthesis [5]. Nevertheless, a number of authors have published successful cases of TAVI in the presence of mechanical valve prostheses [6][7][8][9][10][11][12][13]. In this paper we present four patients who underwent successful TAVI after previous mitral valve surgery.…”

Successful Tavi in Patients with Previous Mitral Valve Replacement

“…Therefore the presence of mitral valve prosthesis is considered a contraindication for TAVI in the currently ongoing Placement of AoRTic TraNscathetER Valve (PARTNER) Trial, which compares TAVI, surgical aortic valve replacement and medical therapy [2]. In spite of this, some case reports have emerged in the last years showing the feasibility of TAVI via transfemoral as well as transapical approach with both available percutaneous aortic prostheses (Edwards Sapien, Edwards Lifesciences, Inc., Irvine, California and CorveValve, Inc., Irvine, California) in patients with artificial mitral valve [3][4][5][6][7][8].…”

“…TAVI in a patient with pre-existent mechanical mitral valve should be considered with caution due to anatomical close proximity of the aortic and mitral annuli [3][4][5][6].…”

“…The authors reported the impor-tance of various methods for guidance: balloon aortic valvuloplasty of a similar balloon size to the valve stent for assessing the expansion and stability of the balloon and no interference with the mitral prosthesis, fluoroscopy and transesophageal echocardiography (TEE) to observe the correct position of the device in relation to the mitral prosthesis and cardiac computed tomographic angiography (CTA) for the assessment of the distance between both annuli and amount of excursion available for the stented valve [3][4][5][6][7][8].…”

“…Recently published cases showed that considering aforementioned conditions TAVI is a feasible option in such patients [3][4][5][6][7][8].…”