Author + information
- Received September 15, 2016
- Accepted October 6, 2016
- Published online December 19, 2016.
- Mizuki Miura, MDa,
- Akihiro Isotani, MDa,
- Kenichiro Murata, MDb,
- Tomohiro Kawaguchi, MDa,
- Masaomi Hayashi, MDa,
- Yoshio Arai, MDc,
- Shinichi Shirai, MDa,∗ (, )
- Michiya Hanyu, MDc and
- Kenji Ando, MDa
- aDepartment of Cardiology, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
- bDepartment of Pathology, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
- cDepartment of Cardiovascular Surgery, Kokura Memorial Hospital, Kitakyushu, Fukuoka, Japan
- ↵∗Reprint requests and correspondence:
Dr. Shinichi Shirai, Department of Cardiology, Kokura Memorial Hospital, 3-2-1 Asano, Kokurakitaku, Kitakyushu, Fukuoka 802-8555, Japan.
An 82-year-old man underwent transcatheter aortic valve replacement (TAVR) for symptomatic severe aortic stenosis (AS) using a 23-mm balloon-expandable SAPIEN XT valve (Edwards Lifesciences, Irvine, California) deployed via a transapical approach (Figure 1A). He was referred to our center for dyspnea (New York Heart Association functional class IV) 6 months after TAVR. Transthoracic echocardiography revealed new mitral regurgitation from the middle of the anterior mitral leaflet (AML) to posterior wall (Figure 1B, Online Video 1). Transesophageal echocardiography revealed perforation of the AML where it made contact with the bottom of the implanted valve (Figures 1C and 1D, Online Videos 2 and 3). He could not undergo open-heart surgery due to a history of coronary artery bypass surgery, poor general health, and frailty. Despite intensive heart failure treatment for a month, he died of progressive low-output syndrome and worsening renal failure. According to the results of autopsy, the AML had been perforated by mechanical stimulation from the implanted valve; however, mitral valve destruction by infectious endocarditis (IE) was not recognized macroscopically (Figure 1E). Microscopically, well-defined disruption of elastic fiber in the mitral valve found in elastica Masson stain, suggesting mechanical stimulation, rather than infectious endocarditis (Figure 1F).
TAVR is an alternative option for patients with severe AS considered inoperable or at high risk for surgical aortic valve replacement. Although the number of TAVR procedures has rapidly increased worldwide, there are few reports about perforation of the AML because of mechanical stimulation late after TAVR without IE. It is important to note this point and avoid low implantation during the TAVR procedure.
For supplemental videos and their legends, please see the online version of this article.
Dr. Ando has received a lecture fee from Medtronic Japan. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received September 15, 2016.
- Accepted October 6, 2016.
- American College of Cardiology Foundation