Case Presentation
A 78-year- old male presented to our Emergency Department for two weeks
history of shortness of breath and peripheral swelling. He had a
previous medical history of several cardio-vascular risk factors,
moderate renal insufficiency (last creatinine level 1.45 mg/dL),
polyarthritis of chronic steroids and permanent atrial fibrillation with
near normal left atrial dimensions. In 2001 he had undergone
mitro-aortic bioprostetic replacement for rheumatic disease with a 29 mm
and 25 mm Magna Edwards bovine prosthesis (Edwards Lifesciences,
Irvine, CA ), respectively. The transthoracic echocardiogram showed a
depressed left ventricular ejection fraction (LVEF) of 28% in the
setting of severe mitro-aortic stenosis, moderate tricuspid
insufficiency and preserved right ventricular function. The patient was
deemed to be at unacceptable high risk for a conventional redo surgery
due to a Euroscore II risk of 16.81% and a Society of Thoracic Surgeon
(STS) score of 13.09% and an elevated frailty index. He underwent multi
detector computed tomography (MDCT) in order evaluate the technical
feasibility of the transcatheter approach (Figure 1 ). Coronary
evaluation showed moderate left anterior descending stenosis (60%).
Finally, the Heart team approved a two-steps transcatheter approach. We
chose a transfemoral percutaneous aortic valve-in-valve procedure with a
26 mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA ) under
local anesthesia and conscious sedation as first step. In the same
admission, after ten days and computed tomography reassessment of the
prosthesis relationships, we performed a mitral valve-in-valve procedure
with a transapical approach (left antero-lateral minithoracotomy) with
an off-label implantation of a reversed 29 mm Sapien 3 prosthesis
(Edwards Lifesciences, Irvine, CA ). (Figure 2 ). The
postoperative course was uneventful, and the patient was quickly
discharged home. He is alive and well at 2-year follow-up.