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Transapical aortic valve implantation in patients with pre-existing mitral valve prostheses: a case report
© The Author(s). 2016
Received: 28 May 2016
Accepted: 27 July 2016
Published: 8 August 2016
Transcatheter aortic valve implantation (TAVI) has proven to be a valid option for patients with severe aortic stenosis who are at high perioperative risk, particularly in patients with previous cardiac surgery. Several patients with previous mitral valve surgery were reported to have been successfully treated with TAVI.
Two patients, one with mechanical and one with biological mitral valve prosthesis, presented with symptomatic severe aortic stenosis. After discussion among our multidisciplinary heart team transapical approach and a JenaValve™ prosthesis was used for TAVI. Main reasons were to decrease the perioperative risk, avoid a re-opening of the chest via median sternotomy, and discuss the possible superiority of the JenaValve™ device due to its design. The patients were successfully treated and discharged on the 11th and 14th post-operative day, respectively. Echocardiographic follow up before discharge and up to 2.8 years post-operatively showed excellent results.
In conclusion, TAVI in patients with preexisting mitral prostheses-mechanical or biological-is feasible, safe, and effective and offers a valid alternative to conventional aortic valve replacement in this particular re-operation scenario. The JenaValve™ device does not interact with the mitral prosthesis and offers therefore due to its unique design a potential advantage.
Considerable proportion of patients who require mitral valve replacement (MVR) presents with a coexisting pathology of the aortic valve [1, 2] with a possible necessity of surgery of the aortic valve in the following years. On the other hand, the perioperative risk of morbidity and mortality is elevated in patients undergoing conventional aortic valve replacement with previous median sternotomy .
Transcatheter aortic valve implantation (TAVI) is nowadays an approved treatment for aortic stenosis (AS) in patients who are at high surgical risk  and it can further reduce perioperative risk especially in patients who had undergone previous cardiac surgery as there is potentially less surgical trauma . Nevertheless, previous coronary artery bypass grafting (CABG), aortic valve replacement (AVR) or mitral valve replacement pose unknown risks when TAVI is performed.
We report two cases of severe AS treated by transapical TAVI in patients who underwent previously MVR with a mechanical and biological valve, respectively.
Pre-op ΔPmean [mmHg]
Mechanical Valve (Carbomedics, 27 mm)
Biological Valve (Perimount Plus, 27 mm)
Chronic atrial fibrillation
EuroSCORE I [%]
EuroSCORE II [%]
STS-score, PROM [%]
The second case is a 74 year old patient complaining about progressive dyspnea (NYHA III) and episodes of stable load-dependent angina pectoris. Diagnostics also identified a severe aortic valve stenosis (TTE: Δpmean = 41 mmHg; cardiac catheter: Δpmean = 35 mmHg, EOA = 0.7 cm2 (according to Gorlin formula)) and coronary angiography showed still open bypasses after coronary artery bypass grafting in 2011. Due to chronic atrial fibrillation the patient received therapy with vitamin K antagonists as well. In addition to the preoperative demographics (Table 1), the patient received a pacemaker 4 years ago, because of bradyarrhythmia and was suffering from chronic lymphatic leukemia, recently in remission. In contrast to the first case, this patient received a 27 mm biological mitral valve prosthesis (Perimount Plus, Carpentier-Edwards, Irvine, USA) in 2011 with still excellent function.
Preoperative risk evaluation of perioperative mortality using the EuroSCORE (European System for Cardiac Operative Risk Evaluation) and the STS-Score (Society of Thoracic Surgeons) showed a high perioperative risk for both patients (Table 1). Furthermore, the patients strictly denied surgical aortic valve replacement via median sternotomy.
Intra- and postoperative data
Skin-to-skin time [min]
Ventilation time [h]
Total hospital stay [d]
Aortic regurgitation discharge
Paravalvular leakage discharge
ΔPmean [mmHg] discharge
Paravalvular leakage follow up
ΔPmean [mmHg] follow up
Mitral prosthesis dysfunction follow up
After a few reports about implanting JenaValve™ in patients with mechanical mitral valve prosthesis [9, 10], we report here a case of transcatheter aortic valve implantation using the self-expandable JenaValve™ in a patient with history of biological mitral valve prosthesis.
Patients with symptomatic aortic valve stenosis that qualify for transcatheter implantation with pre-existing both, biological or mechanical mitral valve prostheses, are still a rare but increasing entity . On the other hand, the perioperative risk of morbidity and mortality is elevated in patients undergoing conventional aortic valve replacement with previous median sternotomy . Since TAVI-procedures were performed patients with pre-existing heart valve prostheses can be offered a new valid therapy option.
The first case of AS treated by TAVI in a patient with previous MVR was reported by Rodes-Gabau in 2008 . Since then further publications reported the use of transapical [9–15], transfemoral [15–20] and even direct aortic  approaches to replace a severely stenotic aortic valve following MVR with different types of mechanical and biological mitral valve prostheses [9–21] or mitral valve reconstructions . Possible complications, the risk of embolization or interference due to the mitral prosthesis’ struts, may complicate those procedures [13, 17]. Therefore, such patients were excluded from the Partner trial  and Medtronic CoreValve U.S. Pivotal Trial .
In contrast to the right ventricle with its dedicated outflow tract the left ventricle has a common aortic-mitral orifice with a close anatomical and physiological relationship between the aortic and mitral valve. The presence of a prosthetic mitral valve reduces the aortic-mitral distance and can therefore complicate an aortic valve implantation . Additionally, the presence of a rigid mechanical structure instead of fibrotic tissue contributes to aggravate the situation . These two mechanisms are the main causes for insufficient opening of the transcatheter valves, dislocation  or embolization . Thus, despite good positioning of the CoreValve® prosthesis (Medtronic Inc., Minneapolis, USA), it can interfere with the opening of the mitral prosthesis’ leaflets and cause a life-threatening situation . Yet an excessively high implantation can lead to aortic regurgitation or even worse occlusion of the coronary arteries . Even dislocating of the Edwards Sapien® (Edwards Lifesciences, Irvine, CA) aortic valve prosthesis into the left ventricle 2 weeks after implantation has been reported .
In pre-existing biological mitral valve prosthesis, which have a different configuration compared to mechanical mitral valve prosthesis with more prominent commissural struts reaching into the left ventricular outflow tract (LVOT), TAVI procedure is even more challenging. Balloon displacement toward the aorta during inflation and valve malposition or embolization has been reported when implanting balloon expandable prostheses .
A minimum distance between the mitral valve prosthesis and the aortic annulus is recommended in both, self-expanding and balloon expandable TAVI to avoid a potential mitral valve dysfunction and to allow the correct expansion of the aortic valve prosthesis [20, 26]. Therefore, preprocedural screening of the patients and particularly the evaluation of mitro-aortic distance should be done precisely by multislice computed tomography . Preoperative and intraprocedural transesophageal echocardiography, as well as fluoroscopy is also essential, to ensure a careful assessment of the patients’ anatomy and to monitor a precise device deployment.
According to our experience, the JenaValve™ is more securing in this setting. Because the locators of the JenaValve™ are positioned into the nadir of the aortic valve sinus the lower margin does not reach more than 2 mm into the LVOT below the aortic annulus and thus offering a reasonable safe distance that is needed to prevent interference with the mitral valve prosthesis during deployment . The possibility of recapturing and repositioning of the device during deployment is also one major advantage to ensure optimal positioning of the prosthesis. Furthermore, a shorter valve length will prevent asymmetrical deployment thus decreasing the risk of paravalvular leakage .
For choosing a transapical versus a transfemoral approach, recommendations should be followed , yet a transapical approach was suggested to be more advantageous  due to more efficient prosthesis maneuvers.
Our report and the previous experience with JenaValve™ [9, 10] suggest that the JenaValve™ prosthesis may offer a potential advantage over other prostheses, due to its design, when implanted in patients with previous mitral valve replacement. However, larger series are needed to proof the anticipated superiority of the JenaValve™ device over other prosthesis.
AS, aortic stenosis; AVR, aortic valve replacement; CABG, coronary artery bypass grafting; CTA, computed tomography angiography; EOA, effective orifice area; EuroSCORE, European System for Cardiac Operative Risk Evaluation; LVOT, left ventricular outflow tract; MVR, Mitral valve replacement; NYHA, New York Heart Association; POD, postoperative day; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation
There are no acknowledgements.
This study has not been funded by any research grant.
Availability of data and materials
As this is a case report, there is no dataset available.
HB and UF made substantial contribution to conception and design of the study. KW, SA, and CR were responsible for acquisition of data. HB, KW, and UF were involved in drafting the manuscript. All authors participated in revising the manuscript and provided important intellectual contributions. All authors gave final approval of the version to be published and take public responsibility for appropriate content of the manuscript. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy of the work are appropriately investigated and resolved.
S. Ahad, U. Franke, and H. Baumbach are working as consultant physician for JenaValve Technology GmbH. H. Baumbach is working as consultant physician for Edwards Lifesciences.
Consent for publication
We do not report individual details and all images are entirely unidentifiable.
Ethics approval and consent to participate
An ethics approval has been requested.
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