Agricola E.

Ancona M. B.

Bellini B.

Chieffo A.

Esposito A.

Ferri L. A.

Gentile D.

Ghizzoni G.

Montorfano M.

Napoli F.

Papageorgiou C.

Romano V.

Russo F.

Vella C.

Zanda G.

English

IRIS UniSR (’Università Vita-Salute San Raffaele)

(2025) 489e492CJC Open 7Case ReportRepeated Transcatheter Valve Interventions After SurgicalMitral Valve Replacement: A 20-Year Journey AvoidingSurgical RedoChristos Papageorgiou, MD,a Marco B. Ancona, MD,a Ciro Vella, MD,a Vittorio Romano, RT,aLuca A. Ferri, MD,a Filippo Russo, MD,a Barbara Bellini, MD,a Giulia Ghizzoni, MD,aGreca Zanda, MD,a Domitilla Gentile, MD,a Francesca Napoli, MD,a Antonio Esposito, MD,b,cEustachio Agricola, MD,c,d Alaide Chieffo, MD,a,c and Matteo Montorfano, MDa,ca Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, ItalybClinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, ItalycVita Salute San Raffaele University, Milan, ItalydCardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, ItalyTranscatheter aortic valve-in-valve (ViV) reinterventionsare indicated for high-risk patients with degeneratedprosthetic valves. However, data are limited on theseinterventions in the setting of a preexisting mitral valveprosthesis. Herein, we present the case of a transcatheteraortic ViV replacement in a patient with a degeneratedbioprosthesis and a history of mitral ViV replacement.Case PresentationA 90-year-old female patient presented with the following:stage IV chronic kidney disease; atrial fibrillation (patient on adirect oral anticoagulant [DOAC]-dose adjusted for renalimpairment); body mass index ¼ 20.9 kg/m2; and a knownhistory of surgical mitral valve replacement in 2005 (Mosaic.27 mm, Medtronic, location) and transcatheter aortic valveintervention (TAVI) in 2017 (Corevalve Evolut R. 29 mm,Medtronic, Minneapolis, MN). She was treated in 2023 formitral prosthesis degeneration with a transfemoral mitral ViVand implantation of an Edwards Sapien 3 Ultra, 26 mm(Edwards Lifesciences, Irvine, CA). One year later, she pre-sented again with recurrence of heart failure (New York HeartAssociation class II-III). Transthoracic echocardiographydemonstrated newly impaired biventricular systolic functionReceived for publication September 24, 2024. Accepted January 29, 2025.Corresponding author: Marco B. Ancona, MD, Interventional CardiologyUnit, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan20142, Italy. Tel.: þ390226437331; fax: þ390226437339.E-mail: ancona.marco@hsr.it@ancona_bSee page 491 for disclosure information.https://doi.org/10.1016/j.cjco.2025.01.0202589-790X/ 2025 The Authors. Published by Elsevier Inc. on behalf of the CanadiaND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).(left ventricular ejection fraction ¼ 35%), normal function ofthe mitral prosthesis (mean gradient, 3 mm Hg), andnewfound severe intra-prosthetic aortic regurgitation (flail ofthe noncoronary prosthetic cusp). Considering the high sur-gical risk (European System for Cardiac Operative RiskEvaluation [EuroSCORE] II; 26.19%) a TAVI-in-TAVIprocedure was scheduled with the use of a supra-annularself-expanding platform (of the same size) to reduce the riskof patienteprosthesis mismatch and the possible risk ofcoronary occlusion. According to multi-slice computedtomography, the level of risk of coronary obstruction andsinus sequestration was deemed to be low (valve to coronary[VTC] distance was 6.3 mm for the left coronary artery and5.9 mm for the right coronary artery; the valve to sinotubularjunction (VTSTJ) distance was 4.54 mm; Fig. 1).The procedure was performed with the patient underconscious sedation. A temporary pacemaker was implanted,and a 5-F pigtail was placed as a marker in the noncoronarycusp. The right femoral artery was used for the insertion of a14-F sheath following suture preclosure of the puncture site.After crossing the ventricle with a stiff guidewire, a newEvolut R, 29 mm, was positioned carefully inside the previousprosthesis, not interfering with the surrounding anatomicborders and structures (aorta, aorto-mitral continuity, neo leftventricular outflow tract) and without contrast. Given that thepreviously implanted valve had not caused coronary obstruc-tion (commissural aligned), the second transcatheter aorticvalve was positioned carefully at the same depth as theprevious one, and with the maximum possible alignment withrespect to preservation of the ostial coronary patency(radiopaque tab markers were used to confirm the alignmentof the 2 devices). The new device was expanded successfullyn Cardiovascular Society. This is an open access article under the CC BY-NC-Novel Teaching Points This case highlights the feasibility and safety of repeatedtranscatheter heart valve interventions during an almost20-year follow-up period, avoiding high-risk surgicalredo. Meticulous pre-procedural planning, based on imagingfindings (multi-slice computed tomography, echocardi-ography), is key for a safe and efficient procedure with ano-contrast technique, particularly in patients with se-vere chronic kidney disease.490 CJC OpenVolume 7 2025(Video 1 , view video online), with no paravalvular leak,a final mean transprosthetic gradient of 4 mm Hg (Fig. 2), nonew conduction disturbances, and preserved hemodynamicprosthetic mitral function (mean transmitral gradient ¼ 3 mmHg). The patient recovered uneventfully and was dischargedon the 3rd postoperative day with the indicatedantithrombotic treatment (continuation of DOAC dosage forrenal impairment) and a recommendation for a follow-up visitat 30 days.DiscussionThe TAVI-in-TAVI procedure following mitral ViVencompasses challenging clinical, anatomic, and technicalconsiderations (bleeding complications, risk of coronaryocclusion, patienteprosthesis mismatch).Figure 1. (A, B) The neo-aortic annulus (1.42 cm) and the mitro-aortic distanthe valve to coronary distance ¼ 5.94 mm; and (E) the valve to sinotubularIn fact, patients with a previous mitral valve prosthesis areat an increased periprocedural risk of bleeding and thromboticcomplications. In our case, the patient already was on amodified dosage of a DOAC, with no concomitant need forantiplatelet treatment. Moreover, even though a ViVprocedure theoretically increases the thrombotic risk (due topotential leaflet thrombosis), no randomized data are availableon the optimal antithrombotic treatment and durationfollowing intervention (single-agent platelet inhibitor therapy[SAPT ] vs DOAC vs dual antiplatelet therapy [DAPT]).Theantithrombotic regimen should be individualized for eachcase, with consideration of the clinical comorbidities andanatomic characteristics of each patient. Thus, the continua-tion of the modified dosage scheme of DOACpost-procedurally was chosen as the most appropriate antith-rombotic strategy. In addition, watchful evaluation was madeof the clinical status, along with assessment of bleeding and/orthrombotic events at the scheduled follow-up visit (includingclinical, and an appropriate stepwise imaging assessment withTTE was performed at the first follow-updand followed by atransesophageal echocardiogram and/or computed tomogra-phy if necessarydfor the timely detection of hypoattenuatedleaflet thickening and/or possible valve thrombosis).Major problems might arise during implantation if inter-ference occurs between the transcatheter heart valve and themitral prosthesis function. Cases of valve embolization andincomplete expansion of the valve also have been reported.1Which types of mitral prosthesis carry higher risk for such acomplication is not known currently; however, a preexistingmechanical mitral prosthesis with highly rigid annular framesand protruding leaflets could increase the risk of possiblece (4.97 mm); (C) the valve-to-coronary artery distance ¼ 6.3 mm; (D)junction ¼ 4.54 mm.Figure 2. (A) Final result; and (B, C) Doppler measurements after the procedure.Papageorgiou et al. 491Transcatheter Interventions Avoiding Surgical Redointerference between devices during implantation. In addi-tion, considering the risk of coronary obstruction and sinussequestration following a ViV procedure (especially for pro-cedures involving a new Evolut valve inside a degeneratedEvolut valve (Medtronic, Minneapolis, MN), causing a highneo-skirt), adequate safe distances of valve to aorta, VTC, andVTSTJ should be ensured during preprocedural planning. Inour case, the valve-to-aorta distance was 2.5 mm above the leftcoronary artery and 4 mm above the right coronary artery; theVTC distance was more than 4 mm for both the left and rightcoronary arteries; and the VTSTJ was 4.5 mm. These mea-surements indicate low risk anatomic features for coronaryocclusion.2,3Moreover, little is known about the optimal assessment ofthe hemodynamic impact on the mitral prosthesis followingTAVI. Data in the literature support the use of the meanmitral gradient for the evaluation of the correct functionafterward, and patients with increased transmitral gradientsfollowing TAVI have been reported to have less-favourablerecovery outcomes.4Attention is warranted for the delineation of themitroaortic distance during implantation, in order to acquireviews for an optimal TAV-in-TAV expansion while avoidingcoronary obstruction. The altered anatomy of the aortomitralcontinuity, the short distance between the mitral prosthesis-aortic annulus and the inflexible assembly of the previous 2bioprosthetic mitral valves comprise significant factors thathave the potential to prevent aortic neoprosthesis expansionand compromise the function of the mitral device afterward.5A cut-off value of > 4 mm for the distance between the aorticannulus and the mitral prosthesis has been strongly advised.Recapturing and repositionable platforms appear to be saferand more efficient in this context.5-7In our case, and given that the distance between the aorticannulus and themitral prosthesis was favourable (4.97mm), weopted for a fully repositionable and recapturable device topromptly anticipate and effectively address the possibility ofinterference with the mitral prosthesis during implantation.Previous reports in the literature regarding similar cases supportthe use of fully repositionable devices (rather than one shoteballoon expandable platforms) in this setting, as they allowthe prompt correction of the implantation position in cases inwhich interference with the mitral prosthesis is recorded.Data AvailabilityAll data are available upon reasonable request.Ethics StatementThe authors declare that the present research fulfills theethical requirements of the Declaration of Helsinki, regardingresearch with human subjects.Patient ConsentWritten consent was provided from the patient.Funding SourcesThe authors have no funding sources to declare.DisclosuresM.M. reports receiving consultant fees from Abbott,Boston, Kardia, and Medtronic. AC reports receiving speakerand consultant fees from Abiomed, Biosensor, Boston Scien-tific, Medtronic, Menarini, and Shock Wave Medical. M.B.A.reports receiving consultant fees from Abbott and Abiomed.C.P. reports receiving a fellowship grant from EuropeanAssociation of Percutaneous Cardiovascular Interventions/Abiomed.492 CJC OpenVolume 7 2025References1. Sarkar K, Speciale G, Ussia GP. Core valve implant failure in the presenceof mechanical mitral prosthesis: importance of assessing left ventricularoutflow tract. Catheter Cardiovasc Interv 2015;85:920-4.2. Grubb KJ, Shekiladze N, Spencer J, et al. Feasibility of redo-TAVI in self-expanding Evolut valves: a CT analysis from the Evolut Low Risk Trialsubstudy. EuroIntervention 2023;19:e330-9.3. Buzzatti N, Montorfano M, Romano V, et al. A computed tomographystudy of coronary access and coronary obstruction after redo transcatheteraortic valve implantation. EuroIntervention 2020;16:e1005-13.4. Amat-Santos I, Cortes C, Nombela Franco L, et al. Prosthetic mitralsurgical valve in transcatheter aortic valve replacement recipients: amulticenter analysis. J Am Coll Cardiol Intv 2017;10:1973-81.5. Asil S, Şahiner L, Necla Özer, et al. Transcatheter aortic valve implantationin patients with a mitral prosthesis; single center experience and review ofliterature. Int J Cardiol 2016;221:390-5.6. Scholtz S, Piper C, Horstkotte D, et al. Transcatheter aortic valve im-plantation in patients with pre-existing mechanical mitral valve prostheses.J Invasive Cardiol 2019;31:260-4.7. Squiers JJ, Potluri S, Brinkman WT, DiMaio JM. Systematic review oftranscatheter aortic valve replacement after previous mitral valve surgery.J Thorac Cardiovasc Surg 2018;155:63-5.Supplementary MaterialTo access the supplementary material accompanying thisarticle, visit CJC Open at https://www.cjcopen.ca/ and athttps://doi.org/10.1016/j.cjco.2025.01.020.

Repeated Transcatheter Valve Interventions After Surgical Mitral Valve Replacement: A 20-Year Journey Avoiding Surgical Redo

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Repeated Transcatheter Valve Interventions After Surgical Mitral Valve Replacement: A 20-Year Journey Avoiding Surgical Redo

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