Anatomic Determinants and Procedural Strategies for TAVR in Patients With Prior Mechanical Mitral Valve Replacement

Transcatheter aortic valve replacement (TAVR) in patients with prior mechanical mitral valve replacement (MVR) is technically challenging because of the altered aortomitral geometry and risk of prosthesis interaction.

We report a single-center series of 5 patients with severe symptomatic rheumatic aortic stenosis and preexisting mechanical MVR who underwent transfemoral TAVR using balloon-expandable and self-expanding valves. Comprehensive preprocedural multidetector computed tomography was used to assess aortomitral distance and angle, annular dimensions, coronary heights, and mitral prosthesis characteristics to guide valve selection and implantation strategy. Procedures were performed under general anesthesia with transesophageal echocardiographic guidance in most cases. Procedural challenges included valve migration, transient mitral prosthesis interaction, and vascular access-related complications, all of which were successfully managed. No patient developed sustained mechanical mitral valve dysfunction, left ventricular outflow tract obstruction, or coronary compromise, and all patients demonstrated favorable short- and mid-term clinical outcomes.

An anatomy-driven, imaging-guided approach enables safe and effective TAVR in select patients with mechanical MVR.

TAVR after mechanical MVR is feasible when guided by meticulous multimodality imaging and disciplined implantation strategy. Procedural success is determined primarily by aortomitral geometry and implantation technique rather than mitral prosthesis type alone.