Associazione Nazionale Medici Cardiologi Ospedalieri



Degeneration of prosthetic heart valves: exciting challenge in Cath Lab

Leonardi Denis Verona (Verona) – Università Degli Studi Di Verona | Del Sole Paolo Alberto Verona (Verona ) – Università Degli Studi Di Verona | Scarsini Roberto Verona (Verona) – Università Degli Studi Di Verona | Lunardi Mattia Verona (Verona) – Università Degli Studi Di Verona | Mammone Concetta Verona (Verona ) – Università Degli Studi Di Verona | Tavella Domenico Verona (Verona) – Università Degli Studi Di Verona | Pesarini Gabriele Verona (Verona) – Università Degli Studi Di Verona | Ribichini Flavio Luciano Verona (Verona ) – Università Degli Studi Di Verona

Background: Prosthetic Heart Valves are always more frequent in the clinical practice. Particularly, sometimes more than one native valve is affected and needs to be surgically treated. On the other side, replaced prosthesis could also degenerate over time, leading to worsening symptomatic heart failure. There are no many cases of combined percutaneous approach to both aortic and mitral prosthetic valve deterioration: our aim is to display a case of this complex clinical setting. 

Case: A 76-year-old man with previous surgical mitral and aortic valve replacement, respectively through Hancock (27 mm) and Mitroflow (21 mm), was referred to our Centre for dyspnoea on mild efforts. Echocardiography revealed severe degeneration of both prosthetic valves, with moderate mitral stenosis (mean pressure gradient – MG – 6 mmHg) and severe central regurgitation, and high transaortic pressure gradients (MG 58; peak pressure gradient – PG – 103 mmHg). Pulmonary hypertension, mild right ventricle dysfunction and reverse flow in hepatic veins were evident. 

Results: The first intervention was Valve-in-Valve Transcatheter Aortic Valve Implantation (ViV TAVI) with CoreValve Evolut PRO+ (23 mm), followed however by recoil determining moderate aortic stenosis (MG 25, PG 47 mmHg). Hence, as both the left prosthetic valves needed treatment, we decided to plan an elective percutaneous procedure aimed to treat both of them. Aortic ViV cracking was successfully obtained through non-compliant Atlas Gold Balloon (22 mm). Then, transseptal puncture by Brockenbrough needle and SL0 dilator sheath system was used to gain access to the left atrium. Finally, after interatrial shunt pre-dilation, Edwards Sapien 3 Ultra (26 mm) was applied as Mitral ViV during rapid ventricle pacing. Echocardiography showed relevant decrease of aortic pressure gradients (MG 11, PG 19) and downgrading of mitral regurgitation from severe to mild, despite unvaried persistent moderate mitral stenosis and signs of chronic severe pulmonary hypertension. The patient was dismissed in 3 days, after adjusting medical therapy. 

Conclusions: Dysfunction of prosthetic heart valves is challenging to be approached, particularly when involving more than one. The expertise of the Centre assumes great importance in this delicate clinical setting. More explanations are further needed to define type and timing of percutaneous intervention aimed to the treatment of multiple prosthetic valves.