Author + information
- Received May 26, 2015
- Accepted June 5, 2015
- Published online November 1, 2015.
- Mike Saji, MD∗,†,
- Gorav Ailawadi, MD‡,
- Michael Ragosta, MD∗,
- Dale E. Fowler, MD, RDCS§,
- John M. Dent, MD∗ and
- D. Scott Lim, MD∗∗ ()
- ∗Advanced Cardiac Valve Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
- †Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
- ‡Advanced Cardiac Valve Center, Department of Surgery, Division of Cardiothoracic Surgery, University of Virginia, Charlottesville, Virginia
- §Heart and Vascular Center, Department of Medicine, Division of Cardiovascular Medicine, University of Virginia, Charlottesville, Virginia
- ↵∗Reprint requests and correspondence:
Dr. D. Scott Lim, Advanced Cardiac Valve Center, Department of Medicine, University of Virginia, 1215 Lee Street, Hospital Expansion, Room 4033, Charlottesville, Virginia 22908.
A 71-year-old man with symptomatic severe aortic stenosis was referred for transcatheter aortic valve replacement (TAVR). His medical history included paroxysmal atrial fibrillation, mild mitral regurgitation, and moderate mitral stenosis with a 10-mm Hg mean transmitral gradient determined using transthoracic echocardiography. Computed tomography (CT) showed mitral annular calcification (MAC) mainly distributed on the anteromedial side of the mitral valve (Figures 1A and 1B). The aortic annulus area, as evaluated using CT, was 600 cm2, and a 29-mm Edwards SAPIEN-XT valve (Edwards Lifesciences, Inc., Irvine, California) was implanted in the optimal position without difficulty (Figure 1C). However, intraoperative transesophageal echocardiography showed a perforation on the medial side of the anterior mitral leaflet (AML) (Figures 1D to 1G, Online Videos 1 and 2). On fluoroscopy, the edge of the SAPIEN-XT valve reached the MAC (Figure 1H). The post-procedural course was uneventful except for transitional atrial fibrillation, and he was discharged on the third postoperative day. The transthoracic echocardiography at the 1-month follow-up did not show evidence of heart failure, infective endocarditis, or deterioration of the transmitral gradient.
Acute AML perforation is a rare complication of TAVR (1). Mitral valve involvement is more likely with the CoreValve prosthesis (Medtronic, Minneapolis, Minnesota) than with the SAPIEN-XT valve because it has a larger component extending into the left ventricular outflow tract (2). However, in this case, the edge of the expanded SAPIEN-XT valve impinged the calcification around the mitral valve, resulting in AML perforation. MAC is considered a risk factor for mitral leaflet perforation, which can lead to heart failure and infective endocarditis. Further follow-up is required in this case, and precise CT assessment for MAC is warranted before TAVR.
For supplemental videos, please see the online version of this article.
Dr. Saji, is a consultant for Abbott Vascular. Dr. Ailawadi is a consultant for Abbott Vascular and Edwards Lifesciences, Inc.; is on the advisory board of Edwards Lifesciences, Inc.; is a speaker for St. Jude; and serves as a proctor for Atricure. Dr. Lim has received industry funding for his research and is a consultant and speaker for Abbott Vascular and Edwards Lifesciences, Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received May 26, 2015.
- Accepted June 5, 2015.
- American College of Cardiology Foundation
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