Transapical Transcatheter Aortic Valve Implantation in the Presence of a Mitral Prosthesis Jia Lin Soon, MD,* Jian Ye, MD,* Samuel V. Lichtenstein, MD, PHD,* David Wood, MD,† John G. Webb, MD,† Anson Cheung, MD* Vancouver, British Columbia, Canada Objectives We review our experience with transapical transcatheter aortic valve implantation (AVI) in patients with function- ing mitral prostheses, and describe the technical considerations. Background Transcatheter AVI for aortic stenosis in patients with mitral prostheses is technically challenging. Methods Ten patients (7 mechanical and 3 bioprosthetic mitral valves) received the Edwards SAPIEN balloon-expandable valve (Edwards Lifesciences, Irvine, California) during 2006 to 2010. All patients were declined conventional sur- gery and prospectively followed. The mean patient age was 77.6  7.1 years (range: 67 to 88 years). The logis- tic EuroSCORE and the Society of Thoracic Surgeons–predicted operative mortality were 30.3  18.6% (range: 11.4% to 70.4%), and 9.9  4.8% (range: 4.6% to 18.7%), respectively. Results All valves were successfully implanted, with no 30-day mortality or mitral prosthetic dysfunction. Nine pa- tients had none to mild residual aortic paravalvular leak. The overall survival was 60% at a mean follow-up of 12.2  10.4 months (range: 2 to 33 months), with 4 nonvalve-related deaths. Seven patients improved to New York Heart Association functional class I to II. The mean transvalvular gradient and effective orifice area improved from 40.0  17.4 mm Hg to 8.2  2.1 mm Hg, and 0.6  0.1 cm 2 to 1.3  0.2 cm 2 , re- spectively (p  0.0001). The mitral bioprosthetic strut predisposes to device “shift” during deployment. An “unfavorable” mechanical mitral prosthetic cage or pivot strut can also cause shifts. Balloon shifts during valvuloplasty warn of a high likelihood of prosthesis shift. Conclusions This report details the technical lessons learned thus far from our first 10 patients. Excellent procedural success and early outcomes in patients with functioning mitral prosthesis can be achieved. (J Am Coll Cardiol 2011;58: 715–21) © 2011 by the American College of Cardiology Foundation Transapical transcatheter aortic valve implantation (AVI) for aortic stenosis and transcatheter valve-in-valve implan- tation for failed aortic bioprostheses have been described using the Edwards SAPIEN balloon expandable valve (Edwards Lifesciences) (1,2). The PARTNER (Placement of AoRTic TraNscathetER Valves) trial demonstrated sig- nificantly reduced mortality, rehospitalization rates and symptoms, in nonsurgical patients undergoing transfemoral AVI, despite the higher incidence of major strokes and vascular events (3). Transcatheter AVI may also be benefi- cial in the elderly with previous coronary bypass and mitral valve replacement. The latter is, however, technically chal- lenging. We report our transapical AVI experience in patients with functioning mitral prosthesis and highlight the technical considerations learned. Methods Ten patients with functioning mitral prostheses underwent transapical AVI for severe symptomatic aortic stenosis using the SAPIEN balloon-expandable bioprosthesis between June 2006 and July 2010. The prosthesis was approved for compassionate use by the department of Health and Wel- fare, Ottawa, Canada, in consenting patients declined for conventional reoperative surgery. All patients were prospec- tively followed. Statistical analysis was performed using SPSS version 18.0 for Windows (SPSS, Chicago, Illinois). Paired Student t test was used to analyze continuous data, and values were expressed as mean  SD. The transapical AVI performed through a 4- to 5-cm left anterolateral mini-thoracotomy has been previously described (4,5). Rapid ventricular pacing (160 to 200 beats/min) was used during balloon valvuloplasty and valve deployment. Bal- From the *Division of Cardiovascular and Thoracic Surgery, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada; and the †Division of Cardiology, St. Paul’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada. Dr. Soon is currently affiliated with the Department of Cardiothoracic Surgery, National Heart Centre Singapore, Singapore. Drs. Ye, Webb, and Cheung are consultants to Edwards Lifesciences. All other authors have reported that they have no relationships to disclose. Manuscript received January 2, 2011; revised manuscript received April 14, 2011, accepted April 19, 2011. Journal of the American College of Cardiology Vol. 58, No. 7, 2011 © 2011 by the American College of Cardiology Foundation ISSN 0735-1097/$36.00 Published by Elsevier Inc. doi:10.1016/j.jacc.2011.04.023