Corevalve prosthesis causes anterior mitral leaflet perforation resulting in severe mitral regurgitation and subsequent endocarditis

An 84-year-old patient presented at our outpatient clinic with recurrent dyspnoea (NYHA class III) and fever. Medical history included transcatheter aortic valve replacement (TAVR) using a 31 mm Corevalve prosthesis 6 months ago. Trans-thoracic echocardiography revealed moderate aortic regurgitation and also perforation of the anterior mitral leaflet (AML) causing severe mitral regurgitation (MR; Panels A1 and A2). Thus, the patient was scheduled for open heart surgery. On admission to the hospital 2 weeks later, trans-oesophageal echocardiography showed evidence of acute new onset endocarditis with small vegetations on the AML and an increase in MR (blue arrow; Panels B1 and B2). Blood smear analyses (six out of six) were positive for Staphylococcus epidermidis, and immediate intravenous antibiotic treatment was administered. Aortic valve (SJM Trifecta 27 mm) and mitral valve (SJM Epic 33 mm) replacement was performed. Trans-aortic in situ video-assisted examination confirmed both endocarditis and AML perforation due to the Corevalve prosthesis stent (green arrow; Panels C1 and C2). Intra- and post-operative course was uneventful. The patient recovered well and was discharged without symptoms and normal valve functions 10 days post-operatively. This report highlights three issues: (i) the danger of AML injury following catheter-based aortic valve replacement, which has not been described thus far; (ii) the potential risk of subsequent endocarditis following TAVR; and (iii) the need for meticulous patient evaluation for TAVR. Although this patient was considered at a high surgical risk, based on his age in the first place, he recovered well from standard double-valve replacement. Supplementary material is available at European Heart Journal online.