Transcatheter aortic valve implantation and mitral valve injury: not too low but not too high
Abstract
Introduction: Transcatheter Aortic valve implantation is a new challenging procedure for frail patient with several co-morbidities. In this case report, the patient developed a mitral valve endocarditis on a post-TAVI mitral valve injury. The level of aortic valve implantation and mitral valve interaction are discussed and may have provoked mitral lesions making the bed of endocarditis.
Case report description: An 81-year-old man with symptomatic severe aortic stenosis was referred for transcatheter aortic valve implantation. Transthoracic Echocardiographic (TTE) assessment confirmed a low-flow low-gradient aortic stenosis, with a mean gradient a moderately impaired left ventricular function and no mitral regurgitation. A 26-mm SAPIEN valve was inserted through a right transfemoral approach. Final valve positioning was performed under rapid ventricular pacing. Post-implantation control was sub-optimal with no aortic regurgitation but the valve position was found to be slightly too high relative to the aortic annulus plane. Discharge TTE showed an optimal valve function with trivial posterior paravalvular regurgitation and mean transprothetic gradient of 8 mmHg. There was no mitral regurgitation. Two weeks later he presented a multi-bacterial infective endocarditis confirmed by 2D transesophageal echocardiography (TEE) with mitral valve injury and perforation of the anterior mitral valve leaflet caused by the ventricular edge of aortic valve stent. A TEE with real-time 3D assessment showed a perforation of the anterior mitral valve leaflet caused by the ventricular edge of aortic valve stent with a 5.7 x 3.5 mm vegetation on the left atrium side. There was a mild to moderate mitral regurgitation and the ventricular tip of the metal stent passed through the mitral valve at each systole. An ECG-gated cardiac Computed tomography confirmed the supra-valvular insertion of the prosthetic aortic valve relative to the annular ring and the sinuses of Valsalva. First line medical strategy was decided and surgical valve replacement was therefore not performed due to high mortality risk and lack of clinical benefit.
Conclusion: This case highlights the need for intra and peri procedural multimodality imaging monitoring to ensure a good deployment and prevent mispositionning of the device. In our case, the high positioning of the prosthesis lead to mitral valve injury making the bed of infective endocarditis secondary to contemporary transient bacteremia.
Keywords
aortic valve
aortic valve insufficiency
aortic valve stenosis
stent
endocarditis
mitral valve insufficiency
transesophageal echocardiography
bacterial endocarditis
left atrium
vegetation
cardiac ct
ventricular dysfunction
left
mitral valve
aortic valve replacement
bacteremia
frail elderly
heart ventricle
paranasal sinuses
surgical procedures
operative
systole
diagnostic imaging
morbidity
mortality
heart valve injury
echocardiography
transthoracic
metallic stents
anulus fibrosus of aorta
devices
medical
ventricular pacing
mitral leaflet
military deployment
transcatheter aortic-valve implantation
paravalvular regurgitation
mitral valve endocarditis
prostheses
aortic valve prosthesis
fluid flow