Concomitant Transcatheter Aortic and Mitral Valve-in-Valve Replacements Using Transfemoral Devices Via the Transapical Approach: First Case in the U.S.

Jun 25, 2013   |  Jean-Michel Paradis, MD; Susheel K. Kodali, MD, FACC; Tamim Nazif, MD; Martin B. Leon, MD, FACC; Mathew Williams, MD
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Figure 1: Concomitant Transcatheter Aortic and Mitral Valve-in-Valve Replacements Using Transfemoral Devices Via the Transapical Approach: First Case in the U.S.

Figure 2: Concomitant Transcatheter Aortic and Mitral Valve-in-Valve Replacements Using Transfemoral Devices Via the Transapical Approach: First Case in the U.S.

Figure 3: Concomitant Transcatheter Aortic and Mitral Valve-in-Valve Replacements Using Transfemoral Devices Via the Transapical Approach: First Case in the U.S.
An 85-year-old man was recently hospitalized at our institution with congestive heart failure and hemolytic anemia. His past medical history was notable for Streptococcus viridans bacterial endocarditis that resulted in severe mitral and aortic regurgitation. In 2002, he underwent surgical aortic valve (Carpentier Edwards #25, Edwards Lifesciences, Irvine, California) and mitral valve (Hancock modified #29, Medtronic, Minneapolis, Minnesota) replacements. During the current admission, a transesophageal echocardiogram demonstrated severe bioprosthetic mitral regurgitation with an effective regurgitant orifice of 0.42 cm2, due to a flail leaflet. The study also revealed severe bioprosthetic aortic stenosis with an aortic valve area (AVA) of 0.9 cm2. Given his symptoms and the TEE findings, the patient was evaluated by the heart team for reoperative aortic and mitral valve replacements. However, he was deemed to be inoperable due to his multiple comorbidities, advanced age, frailty, and the difficulty of the proposed surgery. Thus, the heart team elected to proceed with transapical, transcatheter, double valve-in-valve implantation employing 2 RetroFlex 3 transfemoral devices (Edwards Lifesciences, Irvine, California), which were the only FDA approved devices at the time of the procedure. First, a 26 mm Edwards SAPIEN transcatheter heart valve (THV) was deployed, under rapid pacing, inside the Carpentier Edwards valve in the aortic position. A second 26 mm Edwards SAPIEN THV was then deployed within the Hancock bioprothesis in the mitral position. At the conclusion of the procedure, TEE confirmed excellent position and function of both transcatheter valves. The aortic valve peak and mean gradients were 12 and 6 mmHg, the AVA was 2.08 cm2, and there was no significant paravalvular aortic regurgitation. The mitral valve area was 1.65 cm2, and there was only trace residual mitral regurgitation. The patient was extubated at the conclusion of the procedure and was discharged four days later after an uneventful hospital course. He has been followed as an outpatient and continues to do well more than one year after the concomitant double transcatheter valve-in-valve replacements.

Major concerns during an aortic valve-in-valve procedure include:

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