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

Makoto Tanaka,Toru Naganuma,Shinichi Shirai,Kensuke Takagi,Yusuke Watanabe,Masanori Yamamoto,Hideyuki Shimizu,Masahiro Jinzaki,Keiichi Fukuda,Fumiaki Yashima,Hiroshi Ueno,Kentaro Hayashida,Norio Tada,Kazuki Mizutani,Futoshi Yamanaka,Motoharu Araki,T Arai ,Akira Higashimori ,Minoru Tabata ,Ryoji Yanagisawa

doi:10.1371/journal.pone.0226512

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.

Highlights

Transcatheter aortic valve implantation (TAVI) is an option for patients with severe aortic stenosis with a certain risk for complications of surgical aortic valve replacement [1,2,3]
For patients who have undergone MVR and have a previously implanted mitral prosthesis, TAVI is considered technically challenging because the rigid housing or protruding stem of the prosthesis might interfere with the optimal positioning of the transcatheter heart valve (THV) and increase the risk of valve embolization [4,5,6]
The newly implanted THV could interfere with the preexisting mitral prosthesis [7,8]

Summary

Introduction

Transcatheter aortic valve implantation (TAVI) is an option for patients with severe aortic stenosis with a certain risk for complications of surgical aortic valve replacement [1,2,3]. A previous report demonstrated favorable outcomes in 91 patients with preexisting mitral prostheses who underwent TAVI [6] It reported a relatively high occurrence of THV embolization (6.7%) and suggested that a short distance between the aortic annulus and mitral prosthesis was a potential risk factor for THV embolization. It has commented that new-generation TAVI devices are considered likely to reduce the risk of THV embolization Another concern was the increasing mitral pressure gradient after TAVI, which was reported in the same study [6]. The mechanism behind this phenomenon, including whether the function or morphology of mitral prosthesis is influenced by TAVI, is unclear

Methods

Results

Discussion

Conclusion