- Email: [email protected]
TCTAP C-285 Transseptal Transcatheter Mitral Valve-in-valve Replacement for a Failed Bioprosthetic Mitral Valve
S372
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
TCTAP C-285 Transseptal Transcatheter Mitral Valve-in-valve Replacement for a Failed Bioprosthetic Mitral Valve Do-Yoon Kang,1 Hanbit Park,1 Sang-Cheol Cho,1 Osung Kwon,1 Ungjeong Do,1 Kyusup Lee,1 Jung Ae Hong,1 Se Hun Kang,1 Pil Hyung Lee,1 Jung-Min Ahn,1 Duk-Woo Park,1 Soo-Jin Kang,1 Seung-Whan Lee,1 Young-Hak Kim,1 Cheol Whan Lee,1 Seong-Wook Park,1 Seung-Jung Park1 1 Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (Republic of) [CLINICAL INFORMATION] Patient initials or identifier number. PSR Relevant clinical history and physical exam. A 80-year-old female patient presented with dyspnea with NYHA class III. She had a history of surgical mitral valve replacement with Hancock II(Medtronic) 27 mm bio prosthetic valve 11 years ago due to severe rheumatic mitral stenosis. Other comorbidities included paroxysmal atrial fibrillation, stroke, occlusion of right carotid artery, and restrictive lung disease with healed pulmonary tuberculosis. The Society of Thoracic Surgeons (STS) score was 12.6% and the logistic Euroscore II was 11.8%. Relevant test results prior to catheterization. The transthoracic echocardiography showed a prolapse of a bioprosthetic mitral valve posterior leaflet with severe eccentric mitral regurgitation. As the previous bioprosthesis was Hancock II 27 mm with 24.0 mm of its specified inner diameter and the MDCT analysis showed 23.8 mm of its inner diameter and 460 mm2 of valve area. We selected the Edwards SAPIEN 3 26 mm THV with 519 mm2 of the nominal external valve area, which achieves about 13% area over-sizing. Relevant catheterization findings: [INTERVENTIONAL MANAGEMENT] Procedural step. The procedure was carried out in a hybrid operating room under general anesthesia. Intra procedural imaging was performed with TEE. Thevascular access was obtained in the right common femoral vein. A 6-F pacing catheter was advanced into the right ventricle via left femoral vein for rapid pacing during valve deployment and a 6-F pigtail catheter was advanced into the left ventricle via left femoral artery for left ventriculogram. Transseptalpuncture was performed using standard techniques with Mullins sheath and Brocken brough needle. The atrial septum was sequentially dilated with a 10 x 40 mm Mustang (Boston Scientific) balloon catheter. A 0.035 small-curve Safari wire (Boston Scientific) placed in the left ventricle as the anchor wire and a 14-FE dwards E-sheath was advanced into into left atrium over the Safari wire. The SAPIEN 3 26 mm THV mounted onto the delivery catheter with skirt oriented towards the delivery system handle (atrial side) and delivered antegradely into the dysfunctional bioprosthetic mitral valve. The valve was deployed under rapid ventricular pacing with 180 beats per minute. Left ventriculogram and TEE after valve implantation showed trivial valvular MR without acute complications. The final fluoroscopic image showed that about 20% of the prosthesis was placed on the atrial side of the sewing ring and the prosthesis was not protruded past the radiopaque markers on the leaflets of the Hancock II bioprosthesis.
Case Summary. The patient was monitored in an intensive care unit for two days. Patient’s symptoms subsequently improved from NYHA class III to class I. On day 8 post-procedure, the patient was discharged without serious complications. After one month of procedure, TTE showed trivial valvular MR, mild TR and mild resting pulmonary hypertension. This case proposes the transcatheter mitralvalve-invalve replacement as a promising treatment strategy for patients with failed bioprosthetic mitral valve.
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, VOL. 69, NO. 16, SUPPL S, 2017
TCTAP C-285 Transseptal Transcatheter Mitral Valve-in-valve Replacement for a Failed Bioprosthetic Mitral Valve Do-Yoon Kang,1 Hanbit Park,1 Sang-Cheol Cho,1 Osung Kwon,1 Ungjeong Do,1 Kyusup Lee,1 Jung Ae Hong,1 Se Hun Kang,1 Pil Hyung Lee,1 Jung-Min Ahn,1 Duk-Woo Park,1 Soo-Jin Kang,1 Seung-Whan Lee,1 Young-Hak Kim,1 Cheol Whan Lee,1 Seong-Wook Park,1 Seung-Jung Park1 1 Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (Republic of) [CLINICAL INFORMATION] Patient initials or identifier number. PSR Relevant clinical history and physical exam. A 80-year-old female patient presented with dyspnea with NYHA class III. She had a history of surgical mitral valve replacement with Hancock II(Medtronic) 27 mm bio prosthetic valve 11 years ago due to severe rheumatic mitral stenosis. Other comorbidities included paroxysmal atrial fibrillation, stroke, occlusion of right carotid artery, and restrictive lung disease with healed pulmonary tuberculosis. The Society of Thoracic Surgeons (STS) score was 12.6% and the logistic Euroscore II was 11.8%. Relevant test results prior to catheterization. The transthoracic echocardiography showed a prolapse of a bioprosthetic mitral valve posterior leaflet with severe eccentric mitral regurgitation. As the previous bioprosthesis was Hancock II 27 mm with 24.0 mm of its specified inner diameter and the MDCT analysis showed 23.8 mm of its inner diameter and 460 mm2 of valve area. We selected the Edwards SAPIEN 3 26 mm THV with 519 mm2 of the nominal external valve area, which achieves about 13% area over-sizing. Relevant catheterization findings: [INTERVENTIONAL MANAGEMENT] Procedural step. The procedure was carried out in a hybrid operating room under general anesthesia. Intra procedural imaging was performed with TEE. Thevascular access was obtained in the right common femoral vein. A 6-F pacing catheter was advanced into the right ventricle via left femoral vein for rapid pacing during valve deployment and a 6-F pigtail catheter was advanced into the left ventricle via left femoral artery for left ventriculogram. Transseptalpuncture was performed using standard techniques with Mullins sheath and Brocken brough needle. The atrial septum was sequentially dilated with a 10 x 40 mm Mustang (Boston Scientific) balloon catheter. A 0.035 small-curve Safari wire (Boston Scientific) placed in the left ventricle as the anchor wire and a 14-FE dwards E-sheath was advanced into into left atrium over the Safari wire. The SAPIEN 3 26 mm THV mounted onto the delivery catheter with skirt oriented towards the delivery system handle (atrial side) and delivered antegradely into the dysfunctional bioprosthetic mitral valve. The valve was deployed under rapid ventricular pacing with 180 beats per minute. Left ventriculogram and TEE after valve implantation showed trivial valvular MR without acute complications. The final fluoroscopic image showed that about 20% of the prosthesis was placed on the atrial side of the sewing ring and the prosthesis was not protruded past the radiopaque markers on the leaflets of the Hancock II bioprosthesis.
Case Summary. The patient was monitored in an intensive care unit for two days. Patient’s symptoms subsequently improved from NYHA class III to class I. On day 8 post-procedure, the patient was discharged without serious complications. After one month of procedure, TTE showed trivial valvular MR, mild TR and mild resting pulmonary hypertension. This case proposes the transcatheter mitralvalve-invalve replacement as a promising treatment strategy for patients with failed bioprosthetic mitral valve.