Transcatheter Aortic Valve Replacement after Transcatheter Mitral Valve Replacement

Background: Transcatheter mitral valve replacement (TMVR) in deteriorated prostheses, rings or mitral annular calcification are being performed more frequently. Inadvertently, we are starting to see patients who develop severe aortic stenosis following TMVR. Simultaneous transcatheter aortic valve replacement (TAVR)/TMVR has been previously reported, but almost all are performed in the order of TAVR first then followed by TMVR.

Methods: We included three patients who underwent TAVR following TMVR. The patients subsequently presented with symptomatic aortic stenosis or insufficiency. All procedures were performed from September 2015 to July 2017.

Results: All cases underwent successful TAVR after TMVR. There were several technical points. First, a balloon expandable valve was used for the initial case, but because of the interaction between the balloon and TMVR valve, we elected to use self-expandable valves for the subsequent cases. Secondly, it is critical to confirm that the wire is not traversing a cell of TMVR valve frame. This can be confirmed by fluoroscopy steered to steep left anterior oblique (LAO)/Cranial view to show that the wire is outside of any cells. Thirdly, when the space between the left ventricular outflow tract (LVOT) and the TMVR frame is narrow, there can be an interaction between the self-expanding valve nose-cone and TMVR valve which can bias the transcatheter valve towards the aorta.

Conclusion: TAVR following TMVR poses several technical challenges. We highlight some of the obstacles encountered during the procedure, and offer potential solutions based on our experience. TAVR following previous TMVR can be safely performed with careful attention to wire position and proper valve selection.