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International Society For Minimally Invasive Cardiothoracic Surgery

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Successful Transcathether Implantation Of Self-expandable Prosthesis In A Patient With Existing Mechanical Mitral Valve.
Jan Rychter, Sr.1, Michał Hawranek2, Tomasz Niklewski1, Mariusz Gąsior2, Marian Zembala1, Michał Oskar Zembala1.
1Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland, 23rd Department of Cardiology, Medical University of Silesia in Katowice, Silesian Centre for Heart Diseases, Zabrze, Poland.

BACKGROUND
Treatment of aortic stenosis with transcatheter aortic valve implantation in patient with pre-existing mechanical mitral valve replacement is challenging due to the proximity between the aortic annulus and mechanical mitral valve. Cases of insufficient expansion of the transcatheter prosthesis, dislocation, or embolization have been reported.
METHODS
A 76-year old woman was admitted due worsening symptoms of dyspnea. 20 years ago she underwent mechanical mitral valve replacement and tricuspid valve ring annuloplasty. She had multiple comorbidities, including hypertension, type-2 diabetes, permanent atrial fibrillation, moderate pulmonary hypertension (50mmHg), severe impairment of mobility secondary to hip replacement surgery. Echocardiographic evaluation revealed severe aortic stenosis with moderate calcified aortic valve. The EuroSCORE II risk of in-hospital mortality was 8.71%. Society of Thoracic Surgeons score of the patient for morbidity or mortality was: 11.38%. After multi-disciplinary discussion of Heart Team, patient was qualified for transcatheter aortic valve replacement using ACURATE neo (Boston Scientific, Marlborough, Massachusetts) via transfemoral approach.
RESULTS
The TAVI procedure was performed under local anesthesia with standard hemodynamic monitoring. We successfully implanted Acurate Neo size M prosthesis from right transfemoral surgical cut-down access. Post procedural echocardiography revealed excellent function of Acurate neo prosthesis with gradient max 13 mmHg, mean 7 mmHg, no paravalvular leak and good function of mechanical mitral valve prosthesis. She was discharged home in overall good condition 3 days later.
CONCLUSIONS
The rigid mitral frame within the aortomitral curtain still makes accurate TAVI valves deployment challenging. Increasing the risk of TAVI valve malposition, embolization, or even the lack of full expansion or frame deformation that may contribute to paravalvular leak. Unlike other devices, Boston Scientific ACURATE neo has very low radial force and facilitates optimal implantation with only a few millimeters protruding in left ventricular outflow tract or annulus of mechanical mitral prosthetic valves during procedure. In our patient, ACURATE neo valve showed promising results in terms of safety and feasibility.


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