Totally endoscopic mitral valve replacement for mitral regurgitation post-transcatheter aortic valve implantation: a case report.

Background: Mitral regurgitation (MR) may rarely worsen after transcatheter aortic valve implantation (TAVI) due to mechanical interference from the transcatheter heart valve (THV). Standard surgical approaches in these cases are often challenging due to anatomical constraints. Thus, there is a need for the development of effective alternatives to address this issue. Case summary: We present a case of a 79-year-old male on chronic haemodialysis who developed acute decompensated heart failure following implantation of a self-expanding THV. Transoesophageal echocardiography revealed anterior mitral leaflet (AML) restriction due to direct contact with the THV stent frame. A totally endoscopic mitral valve replacement (MVR), without robotic assistance, was performed via a right mini-thoracotomy. The AML was partially resected, and a 25 mm bioprosthetic valve was successfully implanted in a supra-annular position. The postoperative course was uneventful, and the patient was discharged on Day 6. Discussion: Worsening of MR after TAVI is rare but may occur due to physical interference with mitral valve leaflets. Self-expanding THVs, such as Evolut-FX, may cause leaflet restriction, especially when implanted deep or in patients with small left ventricular outflow tracts. In the present case, the stent protruded beyond the annulus, preventing leaflet motion and leading to symptomatic MR. It was demonstrated that totally endoscopic MVR is a viable minimally invasive approach for post-TAVI MR due to THV interference, even in high-risk patients.