Double-Transcatheter Staged Approach for Aorto-Mitral Valve Disease

 

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Objectives: Despite the fact, that transcatheter valve-in-valve (VinV) implantation is an off-label procedure, it is now well established as an alternative in high-risk patients with failing bioprostheses. Treating a failing mitral bioprosthesis in elderly patients with coexisting severe aortic valve stenosis is even more challenging for the heart team since that operative risk increases in simultaneous procedures. Our aim is to report our experience with a standardized staged transcatheter approach.

Methods: Patients with native aortic and prosthetic mitral valve stenosis underwent a scrupulous workup including left-right heart catheterization and computer tomography. Patients with confirmed double valve stenosis underwent an elective trans-femoral (TF) TAVI intervention as a first step. After discharge and complete recovery, the patients underwent a second operation with trans-apical (TA) implantation of a transcatheter prosthesis in the mitral position (TMVI) as a VinV procedure.

Results: Between 2010 and June 2016, a total of 667 TAVI procedures were performed in our institution. 147 patients had previous cardiac surgery (including 18 mitral valve replacements [MVR]). 3 patients suffered from severe native aortic valve stenosis combined with the degeneration (stenosis) of their mitral bioprosthesis. The first patient was a 76-year old woman (MVR 9 years before, LogES = 38.8%, ES2 = 10.7% for two combined procedures vs. 6.5% for a single non-CABG procedure). A 23-mm Edwards SapienXT TF-TAVI was successfully implanted. 10 weeks after discharge the patient underwent a TA-TMVI (SapienXT 29 mm) as VinV, without complications. She was discharged on the 8^th postoperative day. The second patient was a 81 year old man with a Edwards Perimount 29mm (11 years before; LogE = 38.9%, ES2 = 13.1 vs. 8% for single procedure). A TF-TAVI with 26-mm SapienXT and, after 8 weeks, a TA-TVMI with 29-mm SapienXT were performed successfully. The third patient was a 76-year-old woman with low ejection fraction (20%),degenerated Edwards Perimount 27 mm mitral valve and tricuspid valve repair 10 years before (LogES = 65.4%, ES2 = 29.4 vs. 19.4% for single procedure). 8 weeks after the TF-TAVI (Edwards Sapien3 23 mm), a TA-TMVI with a SapienXT 26mm was performed. She could also be discharged home in good conditions.

Conclusion: The combination of severe aortic stenosis and mitral bioprosthesis failure can be successfully treated with a catheter based, staged approach, with reduced risks and good clinical outcomes.