A Standardized Transcatheter Staged Approach For Aorto-mitral Valve Stenosis: Presentation Of 3 Consecutive Cases
Francesco Pollari1, Michela Cuomo1, Ferdinand Vogt1, Theodor Fischlein1, Jürgen Jessl2, Steffen Pfeiffer1.
1Cardiac surgery, Klinikum Nürnberg - Paracelsus Medical University, Nuremberg, Germany, 2Cardiology, Klinikum Nürnberg - Paracelsus Medical University, Nuremberg, Germany.
OBJECTIVE: 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 valve-in-valve (VinV) procedure.
RESULTS: Between 2010 and October 2016, 708 transcatheter heart valve procedures were performed in our institution. 168 patients had previous cardiac surgery (including 21 mitral valve replacements with bioprosthesis [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, Logistic Euroscore=38.8%, Euroscore2=10.7% considering 2 combined procedures vs 6.5% if considering a single non-cabg procedure). A TF-TAVI with a 23 mm transcatheter heart valve (THV) was successfully implanted. 10 weeks after discharge the patient underwent a TA-TMVI as VinV, without complications. She was discharged on the 8th postoperative day. The second patient was an 81-year-old man with a 29mm bioprosthesis (11 years before Logistic Euroscore=38.9%, Euroscore2=13.1% for 2 procedures vs 8% for single procedure). A TF-TAVI with 26mm THV, and after 8 weeks, a TA-TVMI with 29mm THV was performed successfully. The third patient was a 76-year-old woman with low ejection fraction (20%), degenerated 27 mm mitral valve bioprosthesis and tricuspid valve repair 10 years before (Logistic Euroscore=65.4%, Euroscore2=29.4% for 2 vs 19.4% for single procedure). 8 weeks after the TF-TAVI (23mm THV), a TA-TMVI with a 26mm THV was performed. She could also be discharged home in good conditions.
CONCLUSIONS: 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.
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