Portal de Periódicos da CAPES

Two cases of aneurysm of the anterior mitral valve leaflet associated with transcatheter aortic valve endocarditis: A mere coincidence?

2010; Elsevier BV; Volume: 140; Issue: 3 Linguagem: Inglês

10.1016/j.jtcvs.2009.11.012

1097-685X

Nicolò Piazza, Sebastanio Marra, John G. Webb, Maurizio D’Amico, Mauro Rinaldi, Massimo Boffini, Chiara Comoglio, Paolo Scacciatella, A. Pieter Kappetein, Peter de Jaegere, Patrick W. Serruys,

Transplantation: Methods and Outcomes

The incidence of transcatheter aortic valve endocarditis (TAVE) is currently unknown. To the best of our knowledge, 2 clinical case reports of TAVE have been published (1 Edwards SAPIEN [Edwards Lifesciences, Irvine, Calif] and 1 Medtronic CoreValve ReValving System [Medtronic CV, Luxembourg Sarl]).1Comoglio C. Boffini M. El Qarra S. Sansone F. D'amico M. Marra S. et al.Aortic valve replacement and mitral valve repair as treatment of complications after percutaneous core valve implantation.J Thorac Cardiovasc Surg. 2009; 138: 1025-1027Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Wong D.R. Boone R.H. Thompson C.R. Allard M.F. Altwegg L. Carere R.G. et al.Mitral valve injury late after transcatheter aortic valve implantation.J Thorac Cardiovasc Surg. 2009; 137: 1547-1549Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Interestingly, both cases were associated with aneurysm and perforation of the anterior mitral valve leaflet—a link that has not been previously reported. We briefly review the clinical presentations of these cases and discuss the possible implications of endocarditis in the context of transcatheter aortic valve implantation. CoreValve ReValving System (Figure 1, A and B). Comoglio and associates1Comoglio C. Boffini M. El Qarra S. Sansone F. D'amico M. Marra S. et al.Aortic valve replacement and mitral valve repair as treatment of complications after percutaneous core valve implantation.J Thorac Cardiovasc Surg. 2009; 138: 1025-1027Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar reported a case of TAVE in a 66-year-old man who underwent transfemoral aortic valve implantation with the CoreValve ReValving System. The prosthesis was positioned too low into the left ventricular outflow tract, resulting in moderate paravalvular aortic regurgitation. After postimplant balloon dilatation, the aortic regurgitation was reduced to a mild–moderate degree. The postoperative course was complicated by ventricular arrhythmias of unknown etiology. One month after the procedure, the patient was readmitted with heart failure and recurrent ventricular arrhythmias. Echocardiography revealed moderate paravalvular aortic regurgitation, preserved left ventricular function, but progressive left ventricular dilatation. Three months after implantation, the patient had fever and blood cultures positive for Corynebacterium. Transesophageal echocardiography showed severe mitral regurgitation resulting from a perforated aneurysm of the anterior mitral valve leaflet at the level of the ventricular edge of the metal frame. The patient underwent surgical aortic valve replacement with a 23-mm Carpentier–Edwards bioprosthetic valve (Edwards) and pericardial patch repair of the anterior mitral valve leaflet. In addition to a vegetative lesion observed on the transcatheter aortic valve cusp, the left main coronary artery ostium was obstructed by a strut of the CoreValve frame. The postoperative course was uneventful and the patient was discharged on postoperative day 7. Edwards SAPIEN prosthetic heart valve (Figure 1, C and D). Wong and associates2Wong D.R. Boone R.H. Thompson C.R. Allard M.F. Altwegg L. Carere R.G. et al.Mitral valve injury late after transcatheter aortic valve implantation.J Thorac Cardiovasc Surg. 2009; 137: 1547-1549Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar reported a case of TAVE in an 88-year-old man who underwent transfemoral aortic valve implantation with a 26-mm Edwards SAPIEN prosthetic heart valve. Among other comorbidities, the patient had a history of coronary artery bypass graft surgery. The prosthesis was positioned too low within the left ventricular outflow tract. Postimplant dilatation was performed to mitigate moderate paravalvular aortic regurgitation. At 6 months' follow-up, echocardiography demonstrated trivial aortic and mitral regurgitation. Eleven months after implantation, the patient had fever and Streptococcus anginosus on blood cultures. A dental visit 6 weeks earlier and lack of endocarditis prophylaxis were recorded. Transesophageal echocardiography revealed mild–moderate aortic regurgitation and severe mitral regurgitation owing to a ruptured aneurysm of an anterior mitral valve leaflet located at the contact point of the ventricular edge of the metal stent. The patient underwent redo sternotomy that involved surgical aortic valve replacement with a 25-mm bioprosthesis and pericardial patch repair of the anterior mitral valve leaflet. The postoperative course was complicated by renal failure, pneumonia, delirium, and dysphagia, and he was discharged on postoperative day 38. Although occurring rarely, mitral valve aneurysm is a widely known complication in patients with aortic valve endocarditis. It is caused by the development of satellite infection on the anterior mitral leaflet.3Marcos-Alberca P. Rey M. Serrano J.M. Fernandez-Rozas I. Navarro F. Contreras A. et al.Aneurysm of the anterior leaflet of the mitral valve secondary to aortic valve endocarditis.J Am Soc Echocardiogr. 2000; 13: 1050-1052Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 4Reid C.L. Chandraratna A.N. Harrison E. Kawanishi D.T. Chandrasoma P. Nimalasuriya A. et al.Mitral valve aneurysm: clinical features, echocardiographic–pathologic correlations.J Am Coll Cardiol. 1983; 2: 460-464Abstract Full Text PDF PubMed Scopus (64) Google Scholar By virtue of their design characteristics and final positioning, transcatheter aortic valves may lie in contact with the anterior mitral valve leaflet, intervalvular fibrosa, ventricular septum, aortic root, and ascending aorta. As a result of the contacting surface, transcatheter aortic valves may facilitate satellite infection to these surrounding structures ("bridging endocarditis"). In the 2 cases examined here,1Comoglio C. Boffini M. El Qarra S. Sansone F. D'amico M. Marra S. et al.Aortic valve replacement and mitral valve repair as treatment of complications after percutaneous core valve implantation.J Thorac Cardiovasc Surg. 2009; 138: 1025-1027Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar, 2Wong D.R. Boone R.H. Thompson C.R. Allard M.F. Altwegg L. Carere R.G. et al.Mitral valve injury late after transcatheter aortic valve implantation.J Thorac Cardiovasc Surg. 2009; 137: 1547-1549Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar the prostheses were implanted too low and as a result were in contact with the anterior mitral valve leaflet. Aneurysm of the anterior mitral valve leaflet occurred at the site of contact between the ventricular edge of the infected prosthesis and the anterior mitral valve leaflet. Possibly, tissue injury and endothelial denudation, caused by repetitive friction between the ventricular edge of the prosthesis and the anterior mitral valve leaflet with each heartbeat, might have been a nidus for infection and/or might have promoted aneurysm formation and subsequent rupture. These cases highlight the importance of valve design, valve positioning, and possible complications and extensive surgical repairs that may be required after TAVE. Of even greater importance, these 2 cases should remind us that the concept of sterile "surgical" technique should be mirrored in the cardiac catheterization laboratory during transcatheter valve procedures.