Self-expandable transcatheter aortic valve implantation for aortic stenosis after mitral valve surgery

ORIGINAL ARTICLE – ADULT CARDIAC Interactive CardioVascular and Thoracic Surgery 17 (2013) 90–95 doi:10.1093/icvts/ivt086 Advance Access publication 28 March 2013 Self-expandable transcatheter aortic valve implantation for aortic stenosis after mitral valve surgery Giuseppe Bruschia,*, Federico De Marcoa, Alberto Barosia, Paola Colomboa, Luca Bottaa, Sandra Noninib, Luigi Martinellia and Silvio Klugmanna a b A De Gasperis Cardiology & Cardiac Surgery Department, Niguarda Ca’ Granda Hospital, Milan, Italy Cardiothoracic Anaesthesia and Intensive Care, Niguarda Ca’ Granda Hospital, Milan, Italy * Corresponding author. A De Gasperis Cardiology & Cardiac Surgery Department, Niguarda Ca’ Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milan, Italy. Tel: +39-02-64442565; Fax: +39-02-64442566. E-mail: (G. Bruschi). Abstract OBJECTIVES: Transcatheter aortic valve implantation has emerged as a valuable option to treat patients with symptomatic severe aortic stenosis, who are not being considered for surgery because of significant comorbidities. Concerns exist over treating patients who have previously undergone mitral valve surgery for possible interference between the percutaneous aortic valve and the mitral prosthesis or ring. METHODS: At our centre, from May 2008 to December 2012, 172 patients (76 male) with severe symptomatic aortic stenosis were eligible for transcatheter aortic valve implant. Nine patients, affected by severe aortic stenosis, had previously undergone mitral valve surgery (4 mono-leaflet, 3 bileaflet, 1 bioprosthesis, 1 mitral ring); they were considered high-risk surgical candidates following joint evaluation by cardiac surgeons and cardiologist and had undergone TAVI. RESULTS: Seven patients underwent standard femoral retrograde CoreValve® (Medtronic Inc., Minneapolis, USA) implantation, two patients underwent a direct aortic implantation through a mini-thoracotomy. All patients experienced immediate improvement of their haemodynamic status. No deformation of the nitinol tubing of the CoreValve, nor distortion or malfunction of the mechanical valve or mitral ring, occurred as assessed by echographical and fluoroscopic evaluation. No major postoperative complications occurred. In all patients , echocardiography indicated normal valve function during follow-up. CONCLUSIONS: Our experience confirms the feasibility of CoreValve implantation in patients with mechanical mitral valves or mitral annuloplasty ring. Keywords: Aortic valve • Replacement • Heart valve • Transapical • Percutaneous • Heart valve • Mechanical INTRODUCTION Transcatheter aortic valve implantation (TAVI) has emerged as an important therapeutic strategy to treat patients with severe aortic stenosis (AS) who are at high risk for surgery [1, 2]. Recently, this technique has proven to be as effective as surgery in reducing mortality up to 3 years in this population [3, 4]. Nevertheless, patients with prior mitral valve surgery have often been excluded from this cohort of patients because concerns exist over possible interference between the percutaneous aortic valve and the mitral prosthesis or annuloplasty ring. Indeed previous mitral valve replacement is classified as a contraindication for implantation of the Edwards SAPIEN valve by its manufacturer (Edwards Lifesciences, Irvine, CA, USA) [5]. As a consequence, evidence concerning TAVI outcomes in this group of patients remains sparse and limited to a few case reports. We report our single centre experience with the implantation of the self-expandable CoreValve® (Medtronic Inc., Minneapolis, MN, USA) bioprosthetic aortic valve in nine patients who had previously had mitral valve surgery. PATIENTS AND METHODS At our centre, from May 2008 to December 2012, 172 patients (76 male) with severe symptomatic aortic stenosis, mean age 80 ± 9 years, underwent transcatheter aortic valve implantation. Patient evaluation was in all cases made by the ‘heart team’, composed of a cardiac surgeon, an interventional cardiologist, the referring cardiologist, a cardiac anaesthesiologist and a radiologist. According to the statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Society of Cardiology (ESC) the team’s role is to confirm the severity of aortic stenosis, evaluate patients’ symptoms, analyse surgical risk, evaluate patients’ life expectancy and quality of life and assess the possibility and exclusion of contraindications for TAVI [6]. After the ‘heart team’ evaluation, transcatheter aortic valve © The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Received 4 December 2012; received in revised form 10 February 2013; accepted 14 February 2013 G. Bruschi et al. / Interactive CardioVascular and Thoracic Surgery implantation with a CoreValve prosthesis was preferred in 157 patients. In nine of them (seven female) the procedure was performed as re-operation after previous mitral valve surgery. Written informed consent was obtained from all patients and the local ethics committee approved the procedures. All patients had a logistic EuroSCORE >23% (range 23–77%) and a mean Society of Thoracic Surgeons risk of mortality of 12.7%. In addition to standard transthoracic echocardiogram and coronary angiogram, multislice computed tomography (MSCT) was performed before TAVI in all patients, in order to carefully assess (i) aortic root diameters, (ii) peripheral arterial axes and (iii) relationship between aortic annulus and mitral prosthetic valve or ring (Fig. 1A and B). The current third-generation CoreValve® ReValving system with the standard retrograde delivery system was used in all patients. The CoreValve system consists of three unique components: a self-expanding support frame with a tri-leaflet porcine pericardial tissue valve; an 18 Fr catheter delivery system and a disposable loading system: details have been described previously [2]. The procedures were performed by the cardiovascular team, composed of interventional cardiologists, cardiac surgeons with expertise in hybrid procedures and cardiac anaesthesiologists. Pre-procedural antiplatelet treatment consisted of acetylsalicylic acid (100 mg q.d.) and clopidogrel 75 mg q.d. All outcomes were defined according to the Valve Academic Research Consortium (VARC) [7]. 91 Figure 1: Multislice cardiac computed tomography (Fig. 1A) and 3D multislice cardiac computed tomography reconstruction (Fig. 1B), showing the distance between the aortic annulus and the mitral valve housing. Table 1: Baseline preoperative patient characteristics Pt Gender Age (yy) Surgery Years from surgery Redo number STS mortality Prior PPM Preop AF NYHA class 1 2 3 4 5 6 7 8 9 F F F F F M F M F 72 77 60 77 74 31 76 72 83 MVR + TVA MVR + TVA MVR MVR + TVA MVR AVR + MVR + TVA MR + CABG MVR + CABG MVR 21 12 18 11 17 8 6 7 13 1 1 2 2 2 1 1 1 2 7.7 7.8 7 6.8 7.9 36.8 6.1 17.1 17.5 0 1 (...truncated)