Anterior Mitral Leaflet (AML) Endocarditis and Perforation after Self-expanding TAVI

Deep implantation of self-expanding TAVI-prostheses may result in higher rates of AV-blocks, pacemaker implantations and paravalvular leaks (PVL). Even when touching the AML with the inferior portion of the frame, impairment of the mitral valve is rarely described. We report on a case of AML-perforation due to endocarditis early after TAVI. An 85-year-old male patient presented with severe aortic stenosis, moderate mitral insufficiency and moderate-to-severe tricuspid insufficiency. Due to age and risk profile, transfemoral TAVI was considered the appropriate way of treatment by the institutional heart team. In multi-slice computed tomography (MSCT), the annular size was measured to be 31mm (perimeter based), the angulation of the annular level was calculated as 60°, so a 34 mm self-expanding TAVI-prosthesis (Evolut R, Medtronic) was chosen. During the implantation, the left sinus portion of the prosthesis had a tendency to move downstream to the aorta during flaring of the valve; obviously, the severe septal hypertrophy caused this unusual movement. Finally, the intervention ended up with an oblique implantation of the Evolut R, with the noncoronary portion rather deep, while the left coronary portion was almost at the level of the annulus. However, there was no PVL, and the patient was discharged on postoperative day 3 in excellent clinical condition. Six weeks later, the patient was readmitted with fever, signs of cardiac decompensation and a systolic murmur above the mitral valve area. TEE revealed a perforation in the AML at the region of contact with the lower rim of the frame, and structures consistent with infectious vegetations. Immediate surgical double valve replacement was performed, the intraoperative situation verified the echocardiographic findings. The patient was extubated hours after surgery in stable conditions and recovered well from the operation. High implantation of the self-expanding Evolut R has demonstrated to yield best immediate and long-term results. In this case, however, septal hypertrophy caused atypical oblique tilting of the prosthesis, resulting in a deep implantation at the noncoronary sinus. The case described shows, that deep implantation may not only lead to conduction disorders and PVL, but also to damage of the mitral valve. Severe septal hypertrophy may create a challenge, which is not yet met by commercially available TAVI prostheses.