Transapical transcatheter aortic valve implantation in the presence of a mitral prosthesis.

OBJECTIVES: We review our experience with transapical transcatheter aortic valve implantation (AVI) in patients with functioning mitral prostheses, and describe the technical considerations.

BACKGROUND: Transcatheter AVI for aortic stenosis in patients with mitral prostheses is technically challenging.

METHODS: 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.

RESULTS: 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.

CONCLUSIONS: 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.