Percutaneous Treatment of Severe Aortic Regurgitation After Surgical Mitral Valve Repair

A 54-year-old woman who had recently undergone surgical mitral and tricuspid valve repair was diagnosed with severe aortic regurgitation. She was scheduled for percutaneous treatment and underwent successful transcatheter aortic valve implantation with a 27-mm Trilogy valve (JenaValve Technology). The case documents feasibility of percutaneous treatment in the presence of a mitral ring.

index was 38 kg/m 2 .The patient's medication consisted of direct oral anticoagulation and furosemide.
The initial laboratory finding revealed a normal white blood cell count, mild anemia, normal renal and liver function, and negative C-reactive protein.
Her electrocardiogram showed normal sinus rhythm, normal atrioventricular conduction, and narrow QRS.

PAST MEDICAL HISTORY
The patient underwent cardiac surgery for mitral regurgitation (MR) and tricuspid regurgitation in another institution in 2021.The index surgery consisted of mitral valve repair with a 30-mm complete semi-rigid ring implantation, associated with tricuspid repair with ring implantation.The postoperative course was reported uneventful except for paroxysmal atrial fibrillation.

LEARNING OBJECTIVES
To learn the etiology of postsurgical AR.To understand the treatment options for percutaneous treatment of AR.Because there were no previous reports of aortic disease, the differential diagnosis for postsurgical severe AR was between endocarditis and an effect of the surgical intervention.

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The patient did not report any clinically overt sign of infection during the index hospitalization or the past months; moreover, the morphology of the valve appeared normal.However, to rule out the diagnosis of infective endocarditis, we performed blood cultures, the results of which were negative for any bacterial growth. 1 The working hypothesis was that the AR was the consequence of peri-procedural damage of the commissure between the left and noncoronary cusp at the time of the mitral ring suture, 2 probably a mild aortic commissural pinching with the suture needle when securing the ring to the mitral annulus, causing a trivial AR at the moment of the postsurgical echocardiography.It is possible that the ring had then progressively stretched the pinching, thus causing severe AR in a relatively short period of time (Figure 1).

INVESTIGATIONS
Transesophageal echocardiography confirmed severe AR in a tricuspid aortic valve with the origin of the regurgitant jet originating from the commissure between the noncoronary and the left coronary cusp.
The valve leaflets appeared normal, but the noncoronary cusp appeared mildly pinched (Video 2).

MANAGEMENT
The case was brought to the Multidisciplinary Heart Team discussion.The surgical option of reintervention to perform aortic valve replacement was considered technically feasible but at high risk, due to the patient's previous intervention and her morbid obesity. 3A previously reported allergy to warfarin was seen as a further contraindication for a mechanical valve.
The patient underwent a computed tomography The CT analysis raised 2 main concerns: the first was the absolute absence of aortic calcium, which made the option of an off-label implantation of most of the available transcatheter heart valves (THV) unfeasible. 4The second concern was the possibility of valve interaction with the mitral ring 5 as the measured distance from the VBR plane to the ring was only 3 mm (Figure 3).
Hg), a severely enlarged left atrium, normal left ventricle end-diastolic volume with preserved left ventricular ejection fraction, severe aortic regurgitation (AR), moderate tricuspid regurgitation with preserved right ventricular function, elevated pulmonary pressure, and no pericardial effusion (Video 1).

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CT) scan to assess the feasibility of a transcatheter procedure, which revealed the following: virtual basal ring (VBR) perimeter of 82.2 mm, VBR diameter of 30 Â 19 mm, Valsalva sinuses of 32 Â 35 Â 33 mm, right and left coronary height >10 mm, and good bilateral femoral accesses (Figure 2).The aortic calcium score was zero.
The only THV with CE mark approval for the treatment of AR is the Trilogy system (JenaValve Technology) 6 ; this self-expanding supra-annular THV, available in 3 sizes (23-25-27 mm), is made of a nitinol frame and porcine pericardial tissue.The unique design consists of 2 components: the THV itself, with 3 locators that clip onto the native leaflets, and a sealing ring that protrudes into the left ventricular outflow tract (LVOT) ensuring correct sealing.7The amount of metallic frame protruding into the LVOT is the consequence of implantation depth; in case of optimal implantation depth, the minimum protrusion would be expected to be 3 to 5 mm.In this specific case, we predicted contact of the valve with the ring but no associated problems with the implantation result.The final heart team decision was for a percutaneous approach.The patient

FIGURE 3
FIGURE 3 Distance Between the Aortic Annulus and Mitral Ring