Abstract
Transcatheter aortic valve replacement remains challenge in patients with ball-cage-type mechanical valve in mitral position. Potential under-expansion of the percutaneous valve and interaction between the mitral ball-cage mechanical valve tilted towards the left ventricular outflow tract and the percutaneous valve adds risk during and after implantation. We report a successful implantation of the novel CoreValve Evolut-R self-expanding in a patient with severe aortic stenosis and a mitral Starr-Edwards mechanical valve implanted 28 years ago.
Highlights
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Pivoltal Clinical trials have excluded patients with mechanical prosthesis in mitral position because concerns for potential interference between the percutaneous aortic valve and the mitral prosthesis.
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Potential risks during and after implantation include under-expansion of the percutaneous valve and interaction between the mitral ball-cage mechanical valve tilted towards the left ventricular outflow tract and the percutaneous valve.
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The nitinol capsule of Evolut-R CoreValve enhances structural support and its novel delivery recapture system offers optimal features to allow a safe controlled deployment in presence of a ball-cage mechanical mitral prosthesis.
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We report a successful implantation of the novel CoreValve Evolut-R self-expanding in a patient with severe aortic stenosis and a mitral Starr-Edwards mechanical valve implanted 28 years ago.
1
Introduction
Transcatheter aortic valve replacement (TAVR) has emerged as an accepted alternative for high-risk patients with severe symptomatic aortic stenosis (AS) . Pivotal clinical trials have excluded patients with mechanical prosthesis in mitral position because concerns for potential interference between the percutaneous aortic valve and the mechanical mitral prosthesis . It is likely that several patients who underwent mitral valve replacement with old ball-cage mechanical prosthesis might need aortic valve replacement due to severe AS. We reported a challenging TAVR case of a high-risk woman with severe AS who underwent mitral valve replacement 28-years ago with a Starr-Edwards mechanical prosthesis.
2
Case Report
A 72 year-old lady with prior history of cardiac rheumatic disease, chronic atrial fibrillation under oral anticoagulation who underwent mitral valve replacement with a ball-caged mechanical prosthesis in 1987 (Starr-Edwards # 29) presented with progressive shortness of breath. Her general status appeared frail due to small body habitus (weight 56 Kg; height 155 cm) and chronic bilateral lower-limb venous insufficiency. Her laboratory was relevant for mild normocytic anemia (hematocrit 29%) and renal dysfunction (creatinine 1.4 mg/dL, GFR of 38 mL/min/1.73 m 2 ). Her predicted perioperative mortality risk was 6% based on the STS risk score and 26% based on Logistic Euroscore. Transthoracic echocardiogram demonstrated normal functioning of the mitral ball-caged prosthesis, severely dilated left atrium, severe stenotic tricuspid aortic valve with a mean gradient of 58 mmHg, peak gradient of 92 mmHg and estimated area of 0.5 cm2, moderately impaired left ventricular systolic function (ejection fraction of 45%) in addition to severe pulmonary hypertension (70 mmHg) and dilated right-ventricle. Angiogram showed normal coronary arteries and large non-tortuous bilateral ilio-femoral system. Comprehensive evaluation by ECG-gated computed tomography angiogram (CTA) confirmed a tricuspid severely calcified aortic valve with an aortic annulus of 19 × 27 mm, area of 456 mm 2 and a perimeter of 80 mm ( Fig. 1 ). The aortic annulus appears deformed in the posterior aspect due to protrusion of the base of the ring of the mechanical mitral prosthesis ( Fig. 1 ). The aortic-plane and horizontal angle was 56 degrees. A substantial part of the prosthesis cage showed to cross the left ventricular outflow tract (LVOT) on CTA multiplanar reconstruction ( Fig. 2 ). Tomography confirmed wide, straight non-calcified ilio-femoral arteries. TAVR using a self-expandable aortic prosthesis was recommended by the ‘heart team’ due to her high-risk for standard AVR and repeated sternotomy.
The TAVR procedure was performed via right femoral artery under general anesthesia with trans-esophageal echocardiogram (TEE) and fluoroscopic/angiography guidance. Particular attention during wire crossing was given to avoid entreaping the wire across the prosthesis cage. Predilation with a 23 mm aortic balloon (Maxi, Cordis) was performed to ensure wire position outside the prosthesis cage ( Fig. 3 ). In fact, no interaction between the balloon and the cage-ball function was observed.
A 29-mm CoreValve Evolut-R (Medtronic Inc., Minneapolis, MN) prosthesis was retrogradely positioned under angiographic and fluoroscopic guidance ( Fig. 4 ). Slow deployment was successfully performed carefully watching for potential interaction with the mitral valve prosthesis cage. No deformation of the inferior nitinol frame of the CoreValve, neither distortion nor malfunction of the mechanical valve in mitral position occurred, as assessed by TEE and fluoroscopy ( Figs. 5 and 6 ). Mean post-TAVR aortic gradient was 9 mmHg, with mild aortic regurgitation on TEE and angiography ( Figs. 5 and 6 ). The patient underwent VVI pacemaker implantation the 3rd day after TAVR due to slow atrial fibrillation and prolonged pauses. Patient was discharged the 5th day after the index procedure. Two months after the procedure the patient remains in NYHA class 1. Transthoracic echocardiogram confirmed normal function of the aortic prosthesis with minimal paravalvular regurgitation.
