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OBJECTIVE: A 76-years old female was admitted to our emergency room with acute cardiac decompensation due to an acute mitral insufficiency IV°. In her history she had cardiac surgery with aortic valve replacement by 21 mm Solo Freedom bioprosthesis and mitral valve replacement by 27 mm Mosaic bioprosthesis ex domo in 2007.
METHODS: In transesophageal echocardiography a severe aortic stenosis and a strongly suspected endocarditis of the mitral valve bioprosthesis with an abrupted leaflet were diagnosed. The patient had an emergency operation as open surgery due to the expected endocarditis. Introperatively a heavily calcified aortic root, aorto-mitral junction and mitral area like cast in concrete was found. No signs of endocarditis were seen, only a abrupted calcified leaflet causing acute mitral insufficiency IV° and a heavily calcified Solo Freedom bioprosthesis. There was neither a possibility of explanation of the mitral valve bioprosthesis, nor a possibility of place stitches in aortic position due to the calcification. Implantation of an Intuity sutureless aortic valve prosthesis failed because the smallest available prosthesis (19 mm) was too large for the small annulus. Enlargement of the aortic annulus by patch-plasty was impossible due to the calcification. Removement of the whole aortic-mitral-area and followed by reconstruction including aortic and mitral valve replacement seemed to be too dangerous for the frail patient due to expected long operation time.
RESULTS: In an ultima ratio decision we implanted an Edwards Sapien S3 26mm as a valve in valve in the Mosaic 27 mm mitral prosthesis. Implantation of Edwards Sapien S3 23 mm as Valve in Valve in 21 mm Solo Freedom aortic prosthesis was not possible due to coronary obstruction. Finally a Corevalve Evolut R 26 mm was implanted in this position, which made closure of the aortotomy very difficult.
CONCLUSIONS: Postoperatively the patient did well, in the transesophageal echocardiography a correct positioning of the valve prostheses and no insufficiency or paravalvular leakage was detectable.