International Journal of Cardiology 182 (2015) 235–236
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Fatal prosthetic mitral valve encroachment during transcatheter aortic valve implantation Burak Acar ⁎, Serdar Kuyumcu, Selahattin Aydin, Meryem Kara, Mustafa Karakurt, Ozcan Ozeke, Burcu Demirkan, Ahmet Temizhan, Halil Lutfi Kisacik Turkiye Yuksek Ihtisas Training and Research Hospital, Department of Cardiology, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 9 December 2014 Accepted 29 December 2014 Available online 31 December 2014 Keywords: Prosthetic mitral valve Transcatheter aortic valve implantation Aortic stenosis
To the Editor, The transcatheter aortic valve implantation (TAVI) is a great treatment solution for severe aortic stenosis for the patients who have high surgical risk and are not candidate for surgery [1]. Good procedural success and good clinical outcomes have been showed; the main problem is selection of the optimal patient. The presence of previous mechanical mitral prosthesis might complicate the TAVI procedure. However, very limited data exist on TAVI in the setting of a preexisting mitral prosthesis regarding the technique, potential complications, and outcomes [2]. A 63 year-old female patient was admitted to us with shortness of breath, palpitation and intensely decreased exercise tolerance with New York Heart Association Class III. The patient had undergone mitral valve replacement 36 years ago because of the rheumatic valve disease with single tilting disc. Her medical history included chronic hepatitis, hepatic fibrosis, hypertension and hyperlipidemia. Electrocardiography showed atrial fibrillation and non-specific T wave changes. Coronary angiography showed normal coronary arteries. Echocardiography revealed an ejection fraction of 45%, aortic valve area of 0.7 cm2, mean aortic gradient of 44 mm Hg and systolic pulmonary artery pressure of 62 mm Hg. Logistic EuroSCORE was calculated to be 21.38%. TAVI procedure was decided by Heart team as the best treatment option for the patient before her planned liver transplantation. Before the procedure ⁎ Corresponding author at: Türkiye Yüksek İhtisas Hastanesi, Kardiyoloji Klinigi, Ankara 06100, Turkey. E-mail address: [email protected] (B. Acar).
http://dx.doi.org/10.1016/j.ijcard.2014.12.125 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
multislice computed tomography (MSCT) was made for the evaluation the access site and mitroaortic space, however, the area between the aorta and mechanic mitral valve could not BE evaluated due to artifacts. Transesophageal echocardiography was also not conducted because of the esophageal varices. The procedure was carried out in hybrid operating room and a 26 mm Edwards Sapien XT transcatheter valve was implanted via the transfemoral approach under local anesthesia. The valve was implanted with the balloon predilation under rapid ventricular pacing at 180 bpm/min. Right after the valve deployment, the complete heart block developed and an interference between both the prostheses was detected (Video). The patient's hemodynamic status was that of depression and she was taken into the intensive care unit and was inserted with a bipolar temporary pacemaker. Bedside echocardiography showed abnormal function of mitral valve prosthesis with an increased gradient across the valve and thrombus formation in the left atrium (Fig. 1). A surgical consultation excluded the possibility of surgical repair because of poor patient prognosis. Unfortunately, the patient died 1 h after the TAVI procedure. Very limited data exist on TAVI in the setting of a preexisting mitral prosthesis regarding the technique, potential complications, and outcomes [2]. Indeed, most of the previously reported TAVI studies excluded the presence of previous mitral valve surgery [3]. The literature contains only few reports of such patients undergoing transcatheter implantation of an Edwards aortic valve prosthesis. Since the mid-portion of the anterior leaflet of the mitral valve is found in the area between the non-coronary-cusp and the left coronary cusp of the aortic valve [4], the mechanical or native mitral valve might interfere with the expansion of the aortic valve, or vice versa [5,6]. Therefore, several issues should be considered when TAVI is performed in the setting of a preexisting mitral prosthesis [2,7,8]:(a) the measurement of the mitroaortic space; (b) the potential of fully expanding the aortic bioprosthesis without any deformation or distortion of the frame or the valve housing; (c) device embolization due to “watermelon seeding” effect; (d) interference with the prosthetic mitral leaflets or mitral prosthesis deformation affecting functionality; and (e) choice of vascular access [2]. Certain anatomical features such as the angle of the aortic annulus to the horizontal plane, the course of the ascending aorta, and the presence of enough distance to accommodate the valve should be taken into account [2]. Preprocedurally, the aorto-mitral continuity is important during the new aortic valve implantation due to interaction between the aortic bioprosthesis and mechanical mitral valve during TAVI procedure. There were various methods to evaluate the minimum aortic
236
B. Acar et al. / International Journal of Cardiology 182 (2015) 235–236
pre-dilation of the native aortic valve at lesser pacing rates is a very useful method for not only the assessment of the aortic valve diameter, but also the possible interaction. This report suggested that TAVI in the patient with a mechanical mitral valve should be regarded as a dangerous procedure despite the successful case reports reported. The risk increases with balloonexpendable valve stents, thus pre-procedural and intra-procedural assessments are crucial for these patients. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.12.125. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References Fig. 1. Parasternal long axis view of transthoracic echocardiography showing thrombus formation in left atrium due to dysfunction of mitral valve after TAVI procedure. LA: left atrium, LV: left ventricle, RV: right ventricle Ao :aorta.
annulus to mitral valve distance such as transesophageal echocardiography, MSCT and measurement with metric pigtail catheter during angiography [9]. MSCT is the most accurate method for the measurement of the mitroaortic distance [10]. It has been recommended that the minimum distance should be 4 mm for the CoreValve prosthesis and might be slightly less in the Edwards Sapien valve [2]. Since single tilting discs allow for less area in the left ventricular tract for TAVI than double tilting discs, it should be avoided from low implantation technique. Indeed, this distance may be more important in cases of CoreValve implantation, where a portion of the valve frame will extend into the left ventricular outflow tract [2]. Another useful method to prevent this catastrophic complication suggested by Kahlert et al. is that prior to balloon aortic valvuloplasty with thorough observation of the mitral prosthesis during balloon inflation at a relatively slow ventricular rate (~ 160 beats/min) in order to maintain the flow through the mitral valve might be a helpful tool for indicating the feasibility of this approach in these patients [8]. Therefore, balloon valvuloplasty as a part of the TAVI procedure for
[1] R.A. Nishimura, C.M. Otto, R.O. Bonow, B.A. Carabello, J.P. Erwin III, R.A. Guyton, et al., 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines, J. Am. Coll. Cardiol. 63 (2014) e57–e185. [2] M. Vavuranakis, D.A. Vrachatis, M.G. Kariori, C. Moldovan, K. Kalogeras, M. Lavda, et al., TAVI in the case of preexisting mitral prosthesis: tips & tricks and literature review, J. Invasive Cardiol. 26 (2014) 609–612. [3] M.B. Leon, C.R. Smith, M. Mack, D.C. Miller, J.W. Moses, L.G. Svensson, et al., Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery, N. Engl. J. Med. 363 (2010) 1597–1607. [4] K.P. McCarthy, L. Ring, B.S. Rana, Anatomy of the mitral valve: understanding the mitral valve complex in mitral regurgitation, Eur. J. Echocardiogr. 11 (2010) i3–i9. [5] M. Balghith, A. Omran, A. Saileek, A. Alghamdi, H. Najm, Transcatheter aortic valve implantation (core valve) prosthesis complicated by mitral stenosis, J. Saudi Heart Assoc. 24 (2012) 149–150. [6] L. Testa, G. Gelpi, F. Bedogni, Transcatheter aortic valve implantation in a patient with mechanical mitral prosthesis: a lesson learned from an intraventricular clash, Catheter. Cardiovasc. Interv. 82 (2013) E621–E625. [7] N. Dumonteil, B. Marcheix, P. Berthoumieu, P. Massabuau, E. Dieye, I. Decramer, et al., Transfemoral aortic valve implantation with pre-existent mechanical mitral prosthesis: evidence of feasibility, J. Am. Coll. Cardiol. Intv. 2 (2009) 897–898. [8] P. Kahlert, H. Eggebrecht, M. Thielmann, D. Wendt, H.G. Jakob, S. Sack, et al., Transfemoral aortic valve implantation in a patient with prior mechanical mitral valve replacement, Herz 34 (2009) 645–647. [9] J.L. Zamorano, A. Goncalves, R. Lang, Imaging to select and guide transcatheter aortic valve implantation, Eur. Heart J. 35 (2014) 1578–1587. [10] D. Al-Hassan, P. Blanke, J. Leipsic, Multidetector computed tomography in transcatheter aortic valve implantation. Where we stand, Minerva Cardioangiol. 61 (2013) 407–427.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Fatal prosthetic mitral valve encroachment during transcatheter aortic valve implantation Burak Acar ⁎, Serdar Kuyumcu, Selahattin Aydin, Meryem Kara, Mustafa Karakurt, Ozcan Ozeke, Burcu Demirkan, Ahmet Temizhan, Halil Lutfi Kisacik Turkiye Yuksek Ihtisas Training and Research Hospital, Department of Cardiology, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 9 December 2014 Accepted 29 December 2014 Available online 31 December 2014 Keywords: Prosthetic mitral valve Transcatheter aortic valve implantation Aortic stenosis
To the Editor, The transcatheter aortic valve implantation (TAVI) is a great treatment solution for severe aortic stenosis for the patients who have high surgical risk and are not candidate for surgery [1]. Good procedural success and good clinical outcomes have been showed; the main problem is selection of the optimal patient. The presence of previous mechanical mitral prosthesis might complicate the TAVI procedure. However, very limited data exist on TAVI in the setting of a preexisting mitral prosthesis regarding the technique, potential complications, and outcomes [2]. A 63 year-old female patient was admitted to us with shortness of breath, palpitation and intensely decreased exercise tolerance with New York Heart Association Class III. The patient had undergone mitral valve replacement 36 years ago because of the rheumatic valve disease with single tilting disc. Her medical history included chronic hepatitis, hepatic fibrosis, hypertension and hyperlipidemia. Electrocardiography showed atrial fibrillation and non-specific T wave changes. Coronary angiography showed normal coronary arteries. Echocardiography revealed an ejection fraction of 45%, aortic valve area of 0.7 cm2, mean aortic gradient of 44 mm Hg and systolic pulmonary artery pressure of 62 mm Hg. Logistic EuroSCORE was calculated to be 21.38%. TAVI procedure was decided by Heart team as the best treatment option for the patient before her planned liver transplantation. Before the procedure ⁎ Corresponding author at: Türkiye Yüksek İhtisas Hastanesi, Kardiyoloji Klinigi, Ankara 06100, Turkey. E-mail address: [email protected] (B. Acar).
http://dx.doi.org/10.1016/j.ijcard.2014.12.125 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
multislice computed tomography (MSCT) was made for the evaluation the access site and mitroaortic space, however, the area between the aorta and mechanic mitral valve could not BE evaluated due to artifacts. Transesophageal echocardiography was also not conducted because of the esophageal varices. The procedure was carried out in hybrid operating room and a 26 mm Edwards Sapien XT transcatheter valve was implanted via the transfemoral approach under local anesthesia. The valve was implanted with the balloon predilation under rapid ventricular pacing at 180 bpm/min. Right after the valve deployment, the complete heart block developed and an interference between both the prostheses was detected (Video). The patient's hemodynamic status was that of depression and she was taken into the intensive care unit and was inserted with a bipolar temporary pacemaker. Bedside echocardiography showed abnormal function of mitral valve prosthesis with an increased gradient across the valve and thrombus formation in the left atrium (Fig. 1). A surgical consultation excluded the possibility of surgical repair because of poor patient prognosis. Unfortunately, the patient died 1 h after the TAVI procedure. Very limited data exist on TAVI in the setting of a preexisting mitral prosthesis regarding the technique, potential complications, and outcomes [2]. Indeed, most of the previously reported TAVI studies excluded the presence of previous mitral valve surgery [3]. The literature contains only few reports of such patients undergoing transcatheter implantation of an Edwards aortic valve prosthesis. Since the mid-portion of the anterior leaflet of the mitral valve is found in the area between the non-coronary-cusp and the left coronary cusp of the aortic valve [4], the mechanical or native mitral valve might interfere with the expansion of the aortic valve, or vice versa [5,6]. Therefore, several issues should be considered when TAVI is performed in the setting of a preexisting mitral prosthesis [2,7,8]:(a) the measurement of the mitroaortic space; (b) the potential of fully expanding the aortic bioprosthesis without any deformation or distortion of the frame or the valve housing; (c) device embolization due to “watermelon seeding” effect; (d) interference with the prosthetic mitral leaflets or mitral prosthesis deformation affecting functionality; and (e) choice of vascular access [2]. Certain anatomical features such as the angle of the aortic annulus to the horizontal plane, the course of the ascending aorta, and the presence of enough distance to accommodate the valve should be taken into account [2]. Preprocedurally, the aorto-mitral continuity is important during the new aortic valve implantation due to interaction between the aortic bioprosthesis and mechanical mitral valve during TAVI procedure. There were various methods to evaluate the minimum aortic
236
B. Acar et al. / International Journal of Cardiology 182 (2015) 235–236
pre-dilation of the native aortic valve at lesser pacing rates is a very useful method for not only the assessment of the aortic valve diameter, but also the possible interaction. This report suggested that TAVI in the patient with a mechanical mitral valve should be regarded as a dangerous procedure despite the successful case reports reported. The risk increases with balloonexpendable valve stents, thus pre-procedural and intra-procedural assessments are crucial for these patients. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.12.125. Conflict of interest The authors report no relationships that could be construed as a conflict of interest. References Fig. 1. Parasternal long axis view of transthoracic echocardiography showing thrombus formation in left atrium due to dysfunction of mitral valve after TAVI procedure. LA: left atrium, LV: left ventricle, RV: right ventricle Ao :aorta.
annulus to mitral valve distance such as transesophageal echocardiography, MSCT and measurement with metric pigtail catheter during angiography [9]. MSCT is the most accurate method for the measurement of the mitroaortic distance [10]. It has been recommended that the minimum distance should be 4 mm for the CoreValve prosthesis and might be slightly less in the Edwards Sapien valve [2]. Since single tilting discs allow for less area in the left ventricular tract for TAVI than double tilting discs, it should be avoided from low implantation technique. Indeed, this distance may be more important in cases of CoreValve implantation, where a portion of the valve frame will extend into the left ventricular outflow tract [2]. Another useful method to prevent this catastrophic complication suggested by Kahlert et al. is that prior to balloon aortic valvuloplasty with thorough observation of the mitral prosthesis during balloon inflation at a relatively slow ventricular rate (~ 160 beats/min) in order to maintain the flow through the mitral valve might be a helpful tool for indicating the feasibility of this approach in these patients [8]. Therefore, balloon valvuloplasty as a part of the TAVI procedure for
[1] R.A. Nishimura, C.M. Otto, R.O. Bonow, B.A. Carabello, J.P. Erwin III, R.A. Guyton, et al., 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines, J. Am. Coll. Cardiol. 63 (2014) e57–e185. [2] M. Vavuranakis, D.A. Vrachatis, M.G. Kariori, C. Moldovan, K. Kalogeras, M. Lavda, et al., TAVI in the case of preexisting mitral prosthesis: tips & tricks and literature review, J. Invasive Cardiol. 26 (2014) 609–612. [3] M.B. Leon, C.R. Smith, M. Mack, D.C. Miller, J.W. Moses, L.G. Svensson, et al., Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery, N. Engl. J. Med. 363 (2010) 1597–1607. [4] K.P. McCarthy, L. Ring, B.S. Rana, Anatomy of the mitral valve: understanding the mitral valve complex in mitral regurgitation, Eur. J. Echocardiogr. 11 (2010) i3–i9. [5] M. Balghith, A. Omran, A. Saileek, A. Alghamdi, H. Najm, Transcatheter aortic valve implantation (core valve) prosthesis complicated by mitral stenosis, J. Saudi Heart Assoc. 24 (2012) 149–150. [6] L. Testa, G. Gelpi, F. Bedogni, Transcatheter aortic valve implantation in a patient with mechanical mitral prosthesis: a lesson learned from an intraventricular clash, Catheter. Cardiovasc. Interv. 82 (2013) E621–E625. [7] N. Dumonteil, B. Marcheix, P. Berthoumieu, P. Massabuau, E. Dieye, I. Decramer, et al., Transfemoral aortic valve implantation with pre-existent mechanical mitral prosthesis: evidence of feasibility, J. Am. Coll. Cardiol. Intv. 2 (2009) 897–898. [8] P. Kahlert, H. Eggebrecht, M. Thielmann, D. Wendt, H.G. Jakob, S. Sack, et al., Transfemoral aortic valve implantation in a patient with prior mechanical mitral valve replacement, Herz 34 (2009) 645–647. [9] J.L. Zamorano, A. Goncalves, R. Lang, Imaging to select and guide transcatheter aortic valve implantation, Eur. Heart J. 35 (2014) 1578–1587. [10] D. Al-Hassan, P. Blanke, J. Leipsic, Multidetector computed tomography in transcatheter aortic valve implantation. Where we stand, Minerva Cardioangiol. 61 (2013) 407–427.
