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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.
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https://hal.univ-lorraine.fr/hal-01718796
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Submitted on : Tuesday, February 27, 2018 - 4:33:04 PM
Last modification on : Tuesday, October 13, 2020 - 10:46:29 AM

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C. Venner, P. Maureira, Z. Frikha, M. Angioi, T. Folliguet, et al.. Transcatheter aortic valve implantation and mitral valve injury: not too low but not too high. European Heart Journal, Oxford University Press (OUP): Policy B, 2013, 34 (suppl 1), pp.1710 - 1710. ⟨10.1093/eurheartj/eht312.1710⟩. ⟨hal-01718796⟩

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