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IMAGES IN INTERVENTION

Transfemoral Transcatheter Aortic Valve

Implantation in the Presence of Mitral and

Tricuspid Prostheses

Iraj Nazeri, MD,* Seifollah Abdi, MD,* Mohammad Hossein Mandegar, MD,

Farideh Roshanali, MD, Payman Shahabi, MD*

Tehran, Iran

A 53-year-old woman presented to our center withprogressive fatigue and dyspnea on exertion (NewYork Heart Association functional class III). Thepatients medical history was significant for multi-ple cardiac interventions: open mitral commissur-otomy for the treatment of rheumatic mitral ste-nosis 30 years earlier, mitral valve replacement forthe treatment of severe mitral regurgitation at age25 years, and tricuspid valve implantation for thetreatment of rheumatic tricuspid valve regurgita-tion and stenosis 5 years earlier. She had also

undergone several noncardiac surgeries: trauma-related splenectomy 30 years earlier, partial menis-cectomy 27 years ago, tibial external fixation 10years ago, and Billroth II procedure for the treat-ment of peptic ulcer 5 years ago. At the time ofpresentation, she was also under medical treatmentfor hypothyroidism and depression.

Transesophageal echocardiographic (TEE) as-sessment revealed severe aortic stenosis (meansystolic gradient: 47 mm Hg; peak gradient: 98mm Hg; aortic valve area: 0.7 cm2; valve annulus:

From the *Department of Cardiovascular Diseases, Day General Hospital, Tehran, Iran; Department of Cardiac Surgery, Day General Hospital,

Tehran, Iran; and the Department of Radiology, Day General Hospital, Tehran, Iran. The authors have reported that they have no relationshipsrelevant to the contents of this paper to disclose.

Manuscript received June 4, 2012; accepted June 21, 2012.

Figure 1. Fluoroscopy Before and After TAVI

Fluoroscopic images (A) before and (B) after transfemoral aortic valve deployment depicting the prosthetic tricuspid valve (arrowhead)

and mitral prosthesis (asterisk). The arrow indicates the prosthetic aortic valve.

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http://dx.doi.org/10.1016/j.jcin.2012.06.018http://dx.doi.org/10.1016/j.jcin.2012.06.018

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20 mm), moderate aortic regurgitation, functionally normalmitral and tricuspid prosthetic valves, severe pulmonaryhypertension (mean pulmonary artery pressure: 68 mm Hg),and moderately reduced left ventricular function (ejection

fraction: 35%). Selective coronary angiogram revealed nor-mal coronaries.

Due to excessive surgical risk with conventional aorticvalve replacement (logistic EuroSCORE of 15.23%), thepatients was scheduled for transfemoral transcatheter aorticvalve implantation. The procedure was performed undergeneral anesthesia and as previously described (1). Briefly,after aortography, balloon valvuloplasty of the native aorticvalve was performed under rapid ventricular pacing, andsubsequently, a 23-mm Edwards SAPIEN aortic valve (Ed-wards Lifesciences, Irvine, California) was implanted at theaortic annulus (Fig. 1). The procedure was performed without

any complications, and post-procedure and pre-discharge TEErevealed normal aortic prosthetic valve function (peak gradient:12 mm Hg; aortic valve area: 2.2 cm2) with no residual aortic

paravalvular leaks. The patient was discharged on post-procedural day 5; her in-hospital stay had been uneventful.

At 6-month and 1-year follow-up, echocardiographicevaluation revealed normal left ventricular function (ejection

fraction: 55%) and the appropriate position and normalfunction of all 3 prosthetic valves. At these times, she wassymptom free and was in New York Heart Associationfunctional class I.

Reprint requests and correspondence: Dr. Iraj Nazeri, DayGeneral Hospital, Department of Cardiovascular Disease, DayMedical Building, 1225 Valiasr Avenue Tehran 15641, Iran.E-mail:inazeri@yahoo.com.

REFERENCE

1. Cribier A, Eltchaninoff H, Bash A, et al. Percutaneous transcatheterimplantation of an aortic valve prosthesis for calcific aortic stenosis: firsthuman case description. Circulation 2002;106:30068.

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