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Table of Contents
CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 3  |  Page : 109-113  

Percutaneous dual-valve intervention in a high-risk patient with severe aortic and mitral stenosis


1 Trent Cardiac Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
2 University Heart Center Rostock, Rostock, Germany
3 Royal Brompton and Harefield NHS Foundation Trust and Imperial College, London, UK

Date of Web Publication19-Oct-2016

Correspondence Address:
Christoph A Nienaber
Royal Brompton and Harefield NHS Foundation Trust and Imperial College, Sydney Street, London, SW3 6NP
UK
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1995-705X.192563

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   Abstract 

Aortic stenosis is the most frequent and mitral stenosis is the least frequent native single-sided valve disease in Europe. Patients with the combination of severe symptomatic degenerative aortic and mitral stenosis are very rare. Guidelines for the treatment of heart valve diseases are clear for single-valve situations. However, there is no common agreement or recommendation for the best treatment strategy in patients with multiple valve disease and severe concomitant comorbidities. A 76-year-old female patient with the combination of severe degenerative symptomatic aortic and mitral stenosis and several comorbidities including severe obesity, who was found unsuitable surgical candidate by the heart team and unsuitable for two-time general anesthesia in the case of two-step single-valve percutaneous approach by anesthesiologists, underwent successful percutaneous dual-valve single-intervention (transcatheter aortic valve implantation and percutaneous mitral balloon commissurotomy). Percutaneous dual-valve single-intervention is feasible in selected symptomatic high-risk patients.

Keywords: Percutaneous dual-valve single-intervention, percutaneous mitral balloon commissurotomy, transcatheter aortic valve implantation


How to cite this article:
Mrevlje B, Aboukura M, Nienaber CA. Percutaneous dual-valve intervention in a high-risk patient with severe aortic and mitral stenosis. Heart Views 2016;17:109-13

How to cite this URL:
Mrevlje B, Aboukura M, Nienaber CA. Percutaneous dual-valve intervention in a high-risk patient with severe aortic and mitral stenosis. Heart Views [serial online] 2016 [cited 2017 Oct 20];17:109-13. Available from: http://www.heartviews.org/text.asp?2016/17/3/109/192563


   Introduction Top


According to The Euro Heart Survey on Valvular Heart Disease, aortic stenosis (AS) is the most frequent and mitral stenosis (MS) is the least frequent among native single-sided valve diseases in Europe (43.1% vs. 12.1%). In AS, the most common etiology is degenerative, and the least common etiology is rheumatic (81.9% vs. 11.2%), whereas in the case of MS, the situation is just the opposite, rheumatic being the most common and degenerative being the least common etiology (85.4% vs. 12.5%).[1]

Patients with the combination of severe and symptomatic degenerative AS and severe symptomatic degenerative MS are very rare, and there is a lack of data about their frequency in the literature.

According to the current European Guidelines on the Management of Valvular Heart Disease, transcatheter aortic valve implantation (TAVI) is recommended in patients with severe symptomatic AS, who are considered unsuitable for conventional surgery because of severe comorbidities. Likewise, percutaneous mitral balloon commissurotomy (PMC) is recommended in patients with severe symptomatic MS, who are unsuitable for surgery.[2]

We discuss a rare case of an elderly patient with the combination of severe degenerative symptomatic AS and symptomatic MS, who was found unsuitable for surgical treatment by the heart team due to several comorbidities including severe obesity. She was considered also unsuitable for two-time general anesthesia in the case of two-step single-valve percutaneous approach by the anesthesiologists and was subsequently offered a percutaneous dual-valve treatment in a single intervention (TAVI and PMC).

According to our knowledge, this is the first case of this kind described in the literature.


   Case Report Top


A 76-year-old female patient with the combination of severe symptomatic degenerative AS and severe symptomatic degenerative MS was admitted because of acute worsening of heart failure. At the time of presentation, the patient was New York Heart Association (NYHA III) with bilateral peripheral edema and the signs of left-heart failure. Blood-gas analysis showed global respiratory insufficiency.

Moreover, the patient suffered from chronic ischemic heart disease (myocardial infarction 20 years earlier), underwent coronary artery bypass grafting (17 years earlier), stent implantation in saphenous vein graft to first diagonal branch, and the left anterior descending artery (7 years earlier). The patient was also diabetic (oral treatment) and suffered from chronic kidney failure (KDIGO Type IIIA), dyslipoproteinemia, sleep-apnea syndrome, and had severe obesity (body mass index of 53.3).

Baseline diagnostics included coronary angiography [Figure 1], transesophageal echocardiography (TEE) [Figure 2] and [Figure 3], and computed tomography angiography (CTA).
Figure 1: Angiography before intervention. (a) Left anterior descending occlusion, 80% ostial intermediate and left circumflflex stenosis, patent saphenous vein graft to intermediate and first obtuse marginal. (b) Right coronary artery chronic total occlusion. (c) saphenous-vein graft to intermediate and first obtuse marginal. (d and f) Saphenous vein graft to posterior descending artery. (e) Saphenous vein graft to left anterior descending and first diagonal branch. LAD: Left anterior descending, IM: Intermediate, LCX: Left circumflflex, SVG: Saphenous vein graft, OM1: First obtuse marginal, RCA: Right coronary artery, CTO: Chronic total occlusion, PDA: Posterior descending artery, D1: First diagonal branch

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Figure 2: Transesophageal echocardiography before intervention - aortic valve. (a) Heavily calcified tricuspid aortic valve. (b) Peak aortic jet = 4.5 m/s, mean pressure gradient = 49 mmHg, aortic valve area = 0.78 cm2 (ejection fraction = 50%)

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Figure 3: Transesophageal echocardiography before intervention - mitral valve. (a) Anterior and posterior mitral valve leaflflets. (b) Narrow antegrade jet. (c) Three-dimensional echocardiography of joined leaflflets creating two orifices (A1 and A2). (d) Severe mitral stenosis. AL: Anterior leaflflets, PL: Posterior leaflflets, LA: left atrium, LV: Left ventricle, MV: Mitral valve

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With an EuroSCORE II of 16%, the patient was classified as high risk and due to concomitant comorbidities, the heart team found her unsuitable for surgery and repeated general anesthesias.

Before intervention, the patient was scheduled for computed tomography for detailed analysis of aortic root and peripheral arteries. The analysis and measurements were done using the 3mensio software, valve and vascular modules (3mensio Medical Imaging BV, Bilthoven, The Netherlands).

Based on the detailed analysis of all imaging modalities, the strategy was to perform dual-valve single-intervention with PMC - Inou ® Balloon (Toray, Tokyo, Japan) as the first step, followed by TAVI - right femoral approach and 26 mm CoreValve ® (Medtronic, Minneapolis, MN, USA).

PMC and TAVI were performed under the angiographic and TEE guidance [Figure 4] with no periprocedural complications. Postintervention TEE showed an excellent result of PMC with a residual transmitral gradient of 2 mmHg and mild regurgitation [Figure 5], and an excellent result of TAVI (normal pressure gradient over the CoreValve ® and no remaining aortic regurgitation). The proper position and apposition of CoreValve ® were also confirmed with postinterventional CTA [Figure 6]. Postinterventional course was uneventful, free of complication, and the patient was discharged on day 4. At 6-months clinical follow-up, the patient is stable, compensated and NYHA I.
Figure 4: Dual-valve single-intervention. (a) Angiographic control of percutaneous mitral commissurotomy. (b) CoreValve® implantation. (c) Transesophageal echocardiography control of percutaneous mitral commissurotomy. (d) Transesophageal echocardiography control of CoreValve® implantation. (e) Three-dimensional transesophageal echocardiography of mitral valve. (f) Transesophageal echocardiography control of mitral valve after percutaneous mitral commissurotomy. LV: Left ventricle, LA: left atrium, MV: Mitral valve, Ao: Aorta, *: Inou® balloon

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Figure 5: Transesophageal echocardiography control. (a) Successful resolution of mitral stenosis. (b) Remaining mild mitral regurgitation. (c) Successful resolution of aortic stenosis. (d) Absence of CoreValve® regurgitation (arrow)

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Figure 6: Computed tomography angiography control after dual-valve intervention. (a and b) CoreValve® in the aortic root. (c) CoreValve® in the sagittal view. (d) Three-dimensional reconstruction of the thorax with a clearly visible CoreValve®. Ao: Aortic

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   Discussion Top


The first-in-man case of TAVI for the treatment of severe degenerative AS was described by Cribier et al. in 2002. A 57-year-old very high-risk patient (cardiogenic shock, subacute leg ischemia, and several other noncardiac comorbidities) was found unsuitable for surgery and underwent successful TAVI. Four-month follow-up showed satisfactory valvular function; however, the patient died soon after for noncardiac reasons.[3]

Implantation techniques and devices improved since then and TAVI became the standard of treatment for the patients with severe AS, who are unsuitable for surgery.[2] With the aging population and the fact that degenerative AS is the most frequent type of valvular disease, we can expect the rise in the number of TAVI procedures in the near future. Moreover, Cribier et al. have shown noninferiority of TAVI to surgery and the first reports of the CoreValve ® US Pivotal Study 2-year results in high-risk patient population show superior results to surgery, which suggests in the direction of possible superiority of TAVI in all subsets of patients. Clinical trend to treat low- or intermediate-risk patients is already established in many experienced centers, however, for TAVI to become the method of choice also in patients with severe AS, who are otherwise suitable surgical candidates, we need to wait for long-term results of the PARTNER II and SURTAVI trials.[4],[5]

On the other hand, severe MS is a very rare disease in the Western world, and most of the cases are rheumatic in etiology. According to the guidelines, PMC should remain the first choice of treatment in symptomatic patients who are unsuitable for surgery and in younger patients where postponing the surgery is desirable.[2] Tomai et al. have confirmed good long-term results of PMC in the group of patients with rheumatic MS; on the other hand, Tuzcu et al. have shown that PMC is not the best option of treatment for nonrheumatic MS.[6],[7]

In the case of our high-risk patient, who was unsuitable for surgery or two-time anesthesia in the case of two-step single-valve percutaneous approach, dual-valve single-intervention (PMC and TAVI) proved to be a feasible and successful choice of treatment, allowing the patient to improve from NYHA III at the time of presentation to NYHA I at the time of discharge and to remain in the same good condition at a 6-month follow-up.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflflicts of interest.

 
   References Top

1.
Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. Eur Heart J 2003;24:1231-43.  Back to cited text no. 1
    
2.
Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, Alfieri O, Andreotti F, Antunes MJ, Barón-Esquivias G, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012;33:2451-96.  Back to cited text no. 2
    
3.
Cribier A, Eltchaninoff H, Bash A, Borenstein N, Tron C, Bauer F, et al. Percutaneous transcatheter implantation of an aortic valve prosthesis for calcific aortic stenosis:First human case description. Circulation 2002;106:3006-8.  Back to cited text no. 3
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4.
Thyregod HG, Steinbrüchel DA, Ihlemann N, Nissen H, Kjeldsen BJ, Petursson P, et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve stenosis: 1-year results from the all-comers NOTION randomized clinical trial. J Am Coll Cardiol 2015;65:2184-94.  Back to cited text no. 4
    
5.
Cribier A, Durand E, Eltchaninoff H. Patient selection for TAVI in 2014: Is it justified to treat low- or intermediate-risk patients? The cardiologist's view. EuroIntervention 2014;10 Suppl U:U16-21.  Back to cited text no. 5
[PUBMED]    
6.
Tomai F, Gaspardone A, Versaci F, Ghini AS, Altamura L, De Luca L, et al. Twenty year follow-up after successful percutaneous balloon mitral valvuloplasty in a large contemporary series of patients with mitral stenosis. Int J Cardiol 2014;177:881-5.  Back to cited text no. 6
    
7.
Tuzcu EM, Block PC, Griffin B, Dinsmore R, Newell JB, Palacios IF. Percutaneous mitral balloon valvotomy in patients with calcific mitral stenosis: Immediate and long-term outcome. J Am Coll Cardiol 1994;23:1604-9.  Back to cited text no. 7
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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