Mitral valve replacement after transcatheter aortic valve implantation in a patient with rheumatic heart disease and prior Ross procedure: a case report
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Reoperations are required frequently after the Ross procedure in rheumatic patients. The use of transcatheter aortic valve implantation (TAVI) in those patients could decrease the risk of future open procedure; however, the outcome may be affected by the concomitant mitral valve disease, and subsequent mitral reoperation may distort the implanted aortic valve.
We present a female patient who had a beating mitral valve replacement after valve-in-valve TAVI in a patient with prior Ross procedure. Weaning from cardiopulmonary bypass was difficult, and the patient needed extra-cardiac membrane oxygenation (ECMO) and intra-aortic balloon pump because of right ventricular dysfunction. The right ventricular dysfunction could be due to the concomitant coronary artery disease or air embolism during the beating mitral valve surgery. Recovery was gradual, and the patient was discharged after 33 days. Pre-discharge echocardiography showed a maximum gradient of 9 mmHg on the aortic valve and mild paravalvular leak.
Mitral valve replacement in a patient with prior TAVI and the Ross procedure was feasible; it decreased the operative risk and did not distort the implanted aortic valve.
KeywordsBeating mitral valve replacement Ross procedure Transcatheter aortic valve implantation
Extracorporeal membrane oxygenation
Intra-aortic balloon pump
Mitral valve replacement
Transcatheter aortic valve replacement
Despite the low valve-related complications achieved after the Ross procedure in the middle- and young-aged population compared to other prostheses,  the outcome is suboptimal in patients with rheumatic heart disease and re-intervention is common . Currently, the indications of transcatheter aortic valve implantation (TAVI) have been expanded to include low-risk patients ; however, its application in young rheumatic patients has not been evaluated. The risk of complications after TAVI, including all-cause mortality and paravalvular leak, increased in patients with mitral valve disease,  and subsequent mitral valve surgery may affect the implanted aortic valve. The use of TAVI as an adjunctive procedure to surgery to decrease the operative risk has not been evaluated in the literature.
We present a case of rheumatic valve disease who presented after the Ross procedure with moderate aortic stenosis and severe regurgitation, double mitral lesion, and functional tricuspid regurgitation. The patient had valve-in-valve TAVI and beating mitral valve replacement.
The optimal valve prosthesis is still a subject of ongoing researches, and several factors govern the choice of the valve prosthesis for each patient. The Ross procedure has the advantages of growth potential and avoiding the use of anticoagulants, and compared to other prostheses, the Ross procedure was associated with better survival and freedom from valve-related complications when used in young- and middle-aged patients . However, the long-term results are not optimal in rheumatic patients, and those patients require reoperation for autograft dysfunction or mitral valve lesions .
Despite the expansion of TAVI indications to include low-risk patients, technical challenges hinder the use of this technique in all patients, and the risk of future reinterventions will be an issue. Concomitant mitral valve prosthesis increased the complications after TAVI , and it was found that mitral stenosis increased the incidence of post-TAVI paravalvular leak and all-cause mortality .
We presented a case that had the Ross procedure 40 years ago for rheumatic aortic valve disease, and the patient had valve-in-valve TAVI and beating mitral and tricuspid valve surgery. TAVI in patients with prior Ross was rarely reported in the literature . Additionally, the patient had prior aortic valve replacement with a tissue valve, which presents another challenge for TAVI with the possibility of increased postoperative pressure gradient and paravalvular leak. The postoperative maximum pressure gradient on the aortic valve was 9 mmHg, and the patient had a mild para-aortic leak. The degree of paravalvular regurgitation did not increase after mitral valve replacement.
Our patient had heavily calcific aorta, and surgical aortic valve replacement or the aortic-cross clamp would be risky. The risk of air embolism increases with beating mitral valve surgery,  and measures to protect this patient from the risk of air embolism were not feasible because of the hostile aorta. The use of aortic cross-clamp or aortic root vent was not possible; additionally, it may dislodge calcium from the aortic wall and cause systemic embolization with more extensive damage. We believe that the right ventricular dysfunction that occurred after mitral valve replacement was due to air embolism of the right coronary artery. The patient could not be weaned from cardiopulmonary bypass and required mechanical circulatory support. The ventricular function recovered gradually, and the patient was weaned from the circulatory support. Despite the increased risk of air embolism after beating mitral valve surgery, the patient had no clinical or radiological evidence of stroke.
The patient had concomitant coronary artery disease and preoperative mild global hypokinesia of the left ventricle, which could be a risk factor for difficult weaning from cardiopulmonary bypass. However, in-stent thrombosis was a remote possibility since the patient was heparinized and coronary perfusion was maintained throughout the procedure.
Surgical MVR is feasible after TAVI and did not distort the implanted aortic valve or increase the para-valvular leak. Additionally, Ross patients can benefit from TAVI, which decreases the risk of open surgery, especially in those with hostile autograft.
KA performed the surgery, revised the manuscript, and approved the final version. AA wrote the first draft and approved the final version. All authors have read and approved the manuscript.
Ethics approval and consent to participate
Not required for case reports according to the local IRB regulations.
Consent for publication
Not applicable (no identifying images or clinical data were provided for the case)
The authors declare that they have no competing interests.
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