The optimal valve prosthesis is still a subject of ongoing researches, and several factors govern the choice of the valve prosthesis for each patient. The Ross procedure has the advantages of growth potential and avoiding the use of anticoagulants, and compared to other prostheses, the Ross procedure was associated with better survival and freedom from valve-related complications when used in young- and middle-aged patients [1]. However, the long-term results are not optimal in rheumatic patients, and those patients require reoperation for autograft dysfunction or mitral valve lesions [2].
Despite the expansion of TAVI indications to include low-risk patients, technical challenges hinder the use of this technique in all patients, and the risk of future reinterventions will be an issue. Concomitant mitral valve prosthesis increased the complications after TAVI [5], and it was found that mitral stenosis increased the incidence of post-TAVI paravalvular leak and all-cause mortality [4].
We presented a case that had the Ross procedure 40 years ago for rheumatic aortic valve disease, and the patient had valve-in-valve TAVI and beating mitral and tricuspid valve surgery. TAVI in patients with prior Ross was rarely reported in the literature [6]. Additionally, the patient had prior aortic valve replacement with a tissue valve, which presents another challenge for TAVI with the possibility of increased postoperative pressure gradient and paravalvular leak. The postoperative maximum pressure gradient on the aortic valve was 9 mmHg, and the patient had a mild para-aortic leak. The degree of paravalvular regurgitation did not increase after mitral valve replacement.
Our patient had heavily calcific aorta, and surgical aortic valve replacement or the aortic-cross clamp would be risky. The risk of air embolism increases with beating mitral valve surgery, [7] and measures to protect this patient from the risk of air embolism were not feasible because of the hostile aorta. The use of aortic cross-clamp or aortic root vent was not possible; additionally, it may dislodge calcium from the aortic wall and cause systemic embolization with more extensive damage. We believe that the right ventricular dysfunction that occurred after mitral valve replacement was due to air embolism of the right coronary artery. The patient could not be weaned from cardiopulmonary bypass and required mechanical circulatory support. The ventricular function recovered gradually, and the patient was weaned from the circulatory support. Despite the increased risk of air embolism after beating mitral valve surgery, the patient had no clinical or radiological evidence of stroke.
The patient had concomitant coronary artery disease and preoperative mild global hypokinesia of the left ventricle, which could be a risk factor for difficult weaning from cardiopulmonary bypass. However, in-stent thrombosis was a remote possibility since the patient was heparinized and coronary perfusion was maintained throughout the procedure.