Transapical Transcatheter Aortic Valve Implantation in the Presence of a Mitral Prosthesis

Abstract

We review our experience with transapical transcatheter aortic valve implantation (AVI) in patients with functioning mitral prostheses, and describe the technical considerations. Transcatheter AVI for aortic stenosis in patients with mitral prostheses is technically challenging. Ten patients (7 mechanical and 3 bioprosthetic mitral valves) received the Edwards SAPIEN balloon-expandable valve (Edwards Lifesciences, Irvine, California) during 2006 to 2010. All patients were declined conventional surgery and prospectively followed. The mean patient age was 77.6 ± 7.1 years (range: 67 to 88 years). The logistic EuroSCORE and the Society of Thoracic Surgeons-predicted operative mortality were 30.3 ± 18.6% (range: 11.4% to 70.4%), and 9.9 ± 4.8% (range: 4.6% to 18.7%), respectively. All valves were successfully implanted, with no 30-day mortality or mitral prosthetic dysfunction. Nine patients had none to mild residual aortic paravalvular leak. The overall survival was 60% at a mean follow-up of 12.2 ± 10.4 months (range: 2 to 33 months), with 4 nonvalve-related deaths. Seven patients improved to New York Heart Association functional class I to II. The mean transvalvular gradient and effective orifice area improved from 40.0 ± 17.4 mm Hg to 8.2 ± 2.1 mm Hg, and 0.6 ± 0.1 cm² to 1.3 ± 0.2 cm², respectively (p < 0.0001). The mitral bioprosthetic strut predisposes to device "shift" during deployment. An "unfavorable" mechanical mitral prosthetic cage or pivot strut can also cause shifts. Balloon shifts during valvuloplasty warn of a high likelihood of prosthesis shift. This report details the technical lessons learned thus far from our first 10 patients. Excellent procedural success and early outcomes in patients with functioning mitral prosthesis can be achieved.