Transseptal mitral valve-in-valve implantation helps to elucidate the degree of concomitant aortic valve stenosis

Evaluation of the severity of aortic valve stenosis (AVS) in concomitant significant mitral valve regurgitation is challenging. Since the risk of double-valve versus single-valve surgery is remarkably higher, reliable assessment of multivalvular heart disease is crucial, particularly in the case of re-operation [1]. This clinical example demonstrates how a transseptal mitral valve-in-valve implantation may help to elucidate the degree of borderline AVS. In addition, the double wire technique of the valve implantation is presented. A 77-year-old woman after biological valve implantation in 2006 (Hancock II 29 mm) was admitted due to heart failure symptoms (NYHA III). She also suffered from chronic atrial fibrillation, hypertension, hypercholesterolemia, coxarthrosis and spondylarthrosis, and she experienced a brain stem stroke in 2013. Transthoracic and transesophageal echocardiography revealed good left ventricular function (ejection fraction 57%), severe mitral prothesis regurgitation due to leaflet perforation (Figure 1 A) (ERO 0.51 cm2, regurgitation volume 80 ml, maximal/mean gradient 21/6 mm Hg), moderate functional tricuspid valve regurgitation and borderline AVS (aortic valve area (AVA) calculated from the continuity equation 1.1 cm2 and its index (AVAI) 0.67 cm2/m2; on planimetry, AVA 0.98 cm2, AVAI 0.59 cm2/m2; maximal/mean gradient 28/14 mm Hg). Since the stroke volume and its index were borderline (SV 60 ml, SVI 36 ml/m2, respectively) and the mitral regurgitation volume was high, the severity of AVS could not be determined – i.e., it was possible that after fixing the mitral regurgitation the aortic stenosis would become significant, particularly as the calcium score according to multi-slice computed tomography (MSCT) was high (i.e. 1555) [1]. According to EuroSCORE II and STS, the risk of surgical mortality for mitral valve re-operation was 12.21% and 7.6% respectively; however, the risk of a double valve operation was certainly much higher but undetermined. After interdisciplinary discussion, the Heart Team recommended a transcatheter mitral valve-in-valve implantation, then an intra-operative assessment of the aortic valve and a transcatheter aortic valve implantation (TAVI) in the case of significant aortic stenosis. On MSCT, the risk of significant left ventricular outflow tract (LVOT) obstruction was low (the estimated neo-LVOT area was 2.3 cm2). Using a transseptal approach, a 29-mm SAPIEN3 (Edwards Lifesciences) transcatheter...


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