Concomitant Transapical Treatment of Aortic Stenosis and Degenerated Mitral Bioprosthesis With Two 29 mm Edwards Sapien XT Prostheses

Abstract: An 85-year-old woman was admitted to our institution for effort dyspnea. She had a history of mitral valve replacement with a 29 mm Carpentier-Edwards bioprosthesis (Edwards Lifesciences). Transthoracic echocardiography (TTE) showed aortic stenosis and senescence of the mitral bioprosthesis. The heart team opted for a transapical transcatheter aortic valve implantation (TAVI) and mitral valve-in-valve implantation (m-ViV). Two Edwards Sapien XT (ESXT) 29 mm devices were selected. To our knowledge, this is the first description of the concomitant transapical implantation of two 29 mm ESXTs for a combination of failed mitral bioprosthesis and native aortic stenosis.

J INVASIVE CARDIOL 2013;25(12):680-682

Key words: aortic stenosis, transcatheter aortic valve implantation

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Case Description

An 85-year-old woman was admitted to our institution for New York Heart Association class III dyspnea. She had a history of mitral valve replacement, with a 29 mm Carpentier-Edwards bioprosthesis (Edwards Lifesciences), 9 years ago. Clinical examination revealed a diastolic mitral murmur and significant systolic aortic murmur. Transthoracic echocardiography (TTE) showed severe aortic stenosis (effective orifice area [EOA], 0.80 cm²; mean aortic gradient, 60 mm Hg), stenotic senescence of the mitral bioprosthesis (mean transprosthetic gradient, 10 mm Hg), preserved left ventricular ejection fraction (55%), and systolic pulmonary arterial hypertension (55 mm Hg). Coronary angiography did not identify any significant lesion, functional respiratory tests were satisfactory, and no critical stenosis of the supra-aortic trunks was detected by echo color Doppler. Due to the frailty and comorbidities of the patient, the heart team opted for a less invasive treatment by transcatheter aortic valve implantation (TAVI) and mitral valve-in-valve implantation (m-ViV). Considering the potential simplicity of the procedure, with a single access route for both valves, a transapical approach was chosen. Since the area-derived mean aortic annulus diameter, obtained by multislice computed tomography (MSCT), was 25.3 mm (Figure 1) and the inner diameter of the 29 mm Carpentier-Edwards was 27 mm, two 29 mm Edwards Sapien XT  (ESXT) devices were selected. Transapical access was obtained through left anterolateral minithoracotomy. The aortic stenosis was treated first; a 29 mm ESXT was successfully deployed without predilatation and under ventricular pacing. A slight antegrade movement of the balloon was observed during the dual-step inflation, with movement easily controlled by the first operator. Aortography confirmed the patency of the coronary ostia (Figure 2). The second step consisted of predilatation of the mitral bioprosthesis with a 20 mm balloon and consequent deployment of a 29 mm ESXT crimped in a reverse fashion as compared with the aortic one (Figure 3). Transesophageal echocardiography (TEE) showed excellent function of both ESXTs, with trivial paravalvular regurgitation. Day-2 TTE confirmed their correct hemodynamic performance: the aortic EOA was 1.9 cm² with a mean gradient of 5 mm Hg without regurgitation, the mitral EOA was 2 cm² with a mean gradient of 3 mm Hg with trace regurgitation. During the in-hospital follow-up, no stroke or transient ischemic attack occurred and 2 units of red blood cells were transfused as a consequence of a minor drop in the hemoglobin level without any overt source of bleeding. Patient was discharged on day 11 with treatment including aspirin and warfarin. One-month MSCT confirmed the correct position and morphology of the prostheses (Figure 4). At 3-month follow-up, the patient was in New York Heart Association functional class II and TTE showed excellent mitral and aortic performances.  

Discussion

To our knowledge, this is the first description of the transapical implantation of two 29 mm ESXTs for a combination of failed mitral bioprosthesis and native aortic stenosis. Before we comment further, we must note that the use of ViV and the use of the Edwards valve in the mitral position are off label. In the next few years, many patients will suffer from failed surgical bioprosthetic valves. Redo surgery, the standard of care for these patients, can be high risk because of age and comorbidities.^1,2 Several reports have suggested that the off-label use of TAVI within failed surgical bioprosthetic valves (valve-in-valve [ViV]) is feasible, with high procedural success rates and good clinical outcome.³ In the aortic position, the practice of balloon predilatation before ViV is generally avoided or performed with undersized balloons. Indeed, in comparison with native valve leaflets, surgical valves seem more susceptible to tearing after balloon valvuloplasty, leading to acute severe regurgitation, debris embolization, and stroke.⁴ Little is known about the technical challenges encountered during m-ViV. At our center, four transapical m-ViV procedures have been performed using 29 mm ESXT within bioprostheses whose inner diameters ranged from 25 to 27 mm: one Aspire valve (Vascutek; Terumo Corporation) and three Carpentier-Edwards valves. Three cases were performed for stenosis of the prosthesis and 1 case was performed for regurgitation. Although a transseptal approach was feasible, the transapical route was considered to be the easiest for these reasons: (1) direct access to the mitral valve; and (2) shorter distance between the introducer tip and the mitral valve, allowing better control of the ESXT during deployment. In our experience, it was more challenging to perform a retrograde implantation in the presence of mitral stenosis than regurgitation because of the difficulty in crossing the bioprosthesis with the wire and the ESXT. Therefore, an adequate balloon predilatation should be performed for critically stenotic prostheses and avoided in patients with severe regurgitation. New device iterations, like the Ascendra Plus transapical delivery system (Edwards Lifesciences) could simplify the retrograde crossing of the mitral bioprostheses, due to the help of a dedicated nose cone. Finally, it is of paramount importance to assess the exact model, geometry, and inner diameter of the failing mitral prosthesis to accurately plan the intervention. Indeed, the inner diameter of a bioprosthesis can be significantly smaller than the outer diameter depending on the manufacturer and the valve type, while calcific degeneration may lead to a further decrease in the inner diameter. 

Larger cohorts of patients and longer follow-up are needed to validate our findings and appreciate the real risk of stroke during mitral valve-in-valve procedures.

References

1. Maganti M, Rao V, Armstrong S, Feindel CM, Scully HE, David TE. Redo valvular surgery in elderly patients. Ann Thorac Surg. 2009;87(2):521-525.
2. Dvir D, Webb J, Brecker S, et al. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry. Circulation. 2012;126(19):2335-2344.
3. Wilbring M, Alexiou K, Tugtekin SM, et al. Transcatheter valve-in-valve therapies: patient selection, prosthesis assessment and selection, results, and future directions. Curr Cardiol Rep. 2013;15(3):341.
4. McKay CR, Waller BF, Hong R, Rubin N, Reid CL, Rahimtoola SH. Problems encountered with catheter balloon valvuloplasty of  bioprosthetic aortic valves. Am Heart J. 1988;115(2):463-465.

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From the Unitè de Cardiologie Interventionelle, Clinique Pasteur, Toulouse, France.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure
of Potential Conflicts of Interest. Didier Tchetche is a TAVI proctor for Medtronic,
Edwards and Boston Scientific. The other authors report no disclosures.

Manuscript submitted September 12, 2013, provisional acceptance given September
19, 2013, final version accepted October 7, 2013.

Address for correspondence: Leonardo Misuraca, MD, Unitè de Cardiologie Interventionelle,
Clinique Pasteur, 45 Avenue de Lombez, 31076 Toulouse, France. Email:
leo.misuraca@gmail.com