Images and Case Reports in Interventional Cardiology Apical Aortic Valve Implantation in a Patient With a Mechanical Valve Prosthesis in Mitral Position

67-year-old man diagnosed with severe aortic stenosis was admitted to our institution with pulmonary edema. The patient had a history of severe pulmonary fibrosis (total lung capacity, 57% of predicted value; diffusing capacity for carbon monoxide, 33% of predicted value) and had undergone coronary bypass grafting and mitral valve replacement with a St Jude mechanical valve (St Jude Medical, St Paul, Minn) 18 years ago. Doppler echocardiography showed a mean aortic gradient of 36 mm Hg, an aortic valve area of 0.50 cm 2 , and a left ventricular ejection fraction of 45%. Although the mean predicted operative mortality by the Society of Thoracic Surgeons score was 7.5%, the patient was considered at too high risk for surgical aortic valve replacement because of his pulmonary condition, and he was then evaluated for percutaneous aortic valve implantation (PAVI). Transesophageal echocardiography (TEE) showed an aortic annulus of 23 mm as well as proximity between the mitral prosthesis and the aortic annulus (Figure 1A). Contrast computed tomography showed the presence of moderate stenosis and severe calcification of both iliofemoral arteries precluding transfemoral PAVI, and the patient was then proposed for transapical PAVI. The procedure was performed in the operating room under TEE and fluoroscopy guidance by a team of cardiac surgeons and interventional cardiologists using the techniques extensively described in previous reports.1–3 Concerns about the interference of the mitral mechanical prosthesis with the expansion of the new aortic valve and the potential increased risk of valve embolization led us to perform balloon valvuloplasty by transfemoral approach with a 23-mm balloon just before thoracothomy. After valvuloplasty that showed the stability and complete expansion of the balloon, a left anterior minithoracotomy was performed to expose the apex, and 2 large pursestrings with pledgets were placed at the left ventricular apex. After puncturing the apex, a stiff guidewire was positioned in the descending aorta, and a 26F sheath was