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Transapical implantation of an Edwards Sapien valve into a failed prosthetic mitral valve 3 years after a transapical aortic valve implantation
CASE REPORTS
Transapical implantation of an Edwards Sapien valve into a failed prosthetic mitral valve 3 years after a transapical aortic valve implantation Siyamek Neragi-Miandoab, MD, PhD,a Friedrich W. Mohr, MD,b Michael A. Borger, MD,b and David M. Holzhey, MD,b New York, NY, and Leipzig, Germany Bioprosthetic valves are being used with increasing frequency for valve replacement surgery, even in young patients. Because of this, an increasing number of patients From the Department of Cardiovascular and Thoracic Surgery,a Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY; and the Department of Cardiac Surgery,b Heart Center Leipzig, Leipzig, Germany. Disclosures: D.M.H. and B.A.M. have received honoraria from Edwards Lifesciences LLC for lectures and consulting services. All other authors have nothing to disclose with regard to commercial support. Sapien valves are manufactured by Edwards Lifesciences LLC, Irvine, Calif. Received for publication Sept 23, 2012; accepted for publication Oct 2, 2012; available ahead of print Oct 29, 2012. Address for reprints: David M. Holzhey, MD, Heart Center Leipzig, 04289 Leipzig, Germany (E-mail: [email protected]). J Thorac Cardiovasc Surg 2013;145:e19-21 0022-5223/$36.00 Copyright Ó 2013 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2012.10.010
are expected to present with structural bioprosthetic valve degeneration in coming years. The operative mortality and morbidity associated with reoperative mitral valve (MV) surgery remains higher than for first-time operations. Transapical transcatheter mitral valve-in-valve (MVinV) implantation might offer an alternate and safer approach for high-risk patients who are not suitable candidates for surgical MV replacement. A transcatheter valve-in-valve approach has already been shown to be feasible and safe in patients with failed aortic valve (AV) bioprostheses. Moreover, simultaneous transapical transcatheter AV and MV replacement in high-risk patients with previous MV bioprostheses has been reported.1 We report here the case of a patient who underwent 2 separate transapical valvular operations 3 years apart, including an MVinV procedure.
FIGURE 1. A, Adhesions between the apex of the heart and the chest wall. These adhesions did not present a significant challenge for the reoperative transapical approach. B, Measurement of mitral valve bioprosthesis inner diameter in computed tomographic scan. C, Preoperative echocardiogram showing severe stenosis of the mitral bioprosthesis. D, Echocardiogram showing the severity of degenerative changes on the bioprosthesis.
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Case Reports
FIGURE 2. A and B, Implantation of the balloon-expandable valve into the degenerated prosthetic valve in the mitral position. C, Postoperative appearance of deployed valves on chest radiography, with the previous valve in the aortic position and the recent valve in the mitral position. D, Postoperative echocardiogram demonstrating adequate opening of the new mitral prosthesis.
CLINICAL SUMMARY The patient was an 81-year-old white woman who had originally received an MV bioprosthesis (Hancock II, size 29 mm; Medtronic, Inc, Minneapolis, Minn) in 2005 through a standard sternotomy approach. The patient had symptomatic AV stenosis, prompting transapical aortic valve implantation (TA-AVI) with a Sapien valve (Edwards Lifesciences, Irvine, Calif) in 2009. Since then, she had been doing well until a few months before the index visit, when she came to the hospital with progressive symptoms of heart failure (New York Heart Association III or IV functional class). The workup demonstrated degenerative changes on her mitral bioprosthesis causing severe stenosis and secondary pulmonary hypertension (systolic pulmonary arterial pressure, 50-60 mm Hg). A transthoracic echocardiogram demonstrated an enlarged left atrium (58 3 57 mm) and a severely stenotic mitral bioprosthesis, with peak and mean gradients of 34 and 16 mm Hg, respectively. The MV orifice area was 0.8 cm2, and prosthetic valve cusps were severely calcified and immobile (Figure 1). The left ventricular ejection fraction was 40%. After a multidisciplinary discussion with consideration of the patient’s age, operative risk, and multiple comorbidities (including diabetes, hyperthyroidism, systemic and pulmonary hypertension, and previous stroke), the decision was made to perform a transapical MVinV procedure. e20
After induction of general anesthesia, the previous transapical access scar that had been used for TA-AVI was identified and exposed. After placement of 2 purse-string sutures (2-0 Prolene with dissolvable pledgets; Ethicon, Inc, Somerville, NJ), a guide wire was inserted and passed through the MV prosthesis. An Edwards SAPIEN 29-mm valve was crimped and loaded onto the delivery system and then implanted under fluoroscopic and transesophageal echocardiographic guidance (Figure 2). At the end of the procedure, the mitral stenosis had resolved, with a transvalvular gradient of 3 to 4 mm Hg. The patient was extubated a few hours after the procedure. The postoperative course was unremarkable, and the patient was discharged from the hospital on postoperative day 3. DISCUSSION Few studies currently exist of patients who have undergone a transcatheter MVinV procedure. To the best of our knowledge, we present the first case of a patient undergoing an MVinV procedure through a second consecutive transapical approach after previous TA-AVI. With an aging patient population in Europe and North America, combined with an ever increasing proportion of patients undergoing biologic valve replacement surgery, the need for reoperative valvular procedures may be increasing. If patients are young or lacking comorbidities, the standard approach
The Journal of Thoracic and Cardiovascular Surgery c February 2013
Case Reports
remains conventional surgical reoperation. High-risk patients, however, may not tolerate reoperations. The introduction of catheter-based valve implantation has produced a new option of a valve-in-valve approach to failing bioprostheses.2 Without the anatomic difficulties associated with transcutaneous valve implantation in a native mitral annulus or a preexisting mitral annuloplasty ring, performance of the MVinV procedure is relatively straightforward because of the circular bioprosthesis sewing ring, which serves as an excellent landing zone for the transcutaneous valve stent. Cheung and colleagues3 reported a small series of 11 patients (mean Society of Thoracic Surgeons score of 16%) with symptomatic mitral prosthetic valve dysfunction who underwent transapical MVinV. The success rate was 100%, with no 30-day mortality. Nine patients were alive and in New York Heart Association class I or II at a median follow-up of 357 days.3 Similarly, Seiffert and associates4 reported on 6 high-risk patients (EuroSCORE of 33%) who underwent MVinV. Implantation was successful in all patients, with reduction of the transvalvular gradients and median regurgitation from grade 3 to 0. All patients in these studies received a balloon-expandable bovine SAPIEN valve. Despite the fact that Seiffert and associates4 reported postoperative complications in 3 patients, this approach remains acceptable for high-risk patients with a failed bioprosthetic MV. As this case report demonstrates, the transapical method allows access to the AV and MV,
even during the same procedure for patients at very high risk requiring reoperative double valve replacement.5 The unique aspect of this case report is that the patient had undergone a previous TA-AVI procedure. Despite the fact that the apex had previously been used for a TA-AVI operation, we did not have any difficulties with mobilization or cannulation of the apex during the MVinV procedure. With a growing need for reoperative MV replacement for bioprosthetic structural valve deterioration, transcatheter MVinV placement has become as an alternate option. Although the evidence for this approach is limited to a few case reports and small case series, it appears to be a feasible, safe, and promising approach in a select patient population. References 1. Holzhey DM, Schuler G, Mohr FW, Mukherjee C. Transapical double valve implantation plus percutaneous revascularization as a bailout for a high-risk patient. J Thorac Cardiovasc Surg. 2012;144:508-10. 2. Nu~nez-Gil IJ, Gonc¸alves A, Rodrıguez E, Cobiella J, Marcos-Alberca P, Maroto L, et al. Transapical mitral valve-in-valve implantation: a novel approach guided by three-dimensional transoesophageal echocardiography. Eur J Echocardiogr. 2011;12:335-7. 3. Cheung AW, Gurvitch R, Ye J, Wood D, Lichtenstein SV, Thompson C, et al. Transcatheter transapical mitral valve-in-valve implantations for a failed bioprosthesis: a case series. J Thorac Cardiovasc Surg. 2011;141:711-5. 4. Seiffert M, Conradi L, Baldus S, Schirmer J, Knap M, Blankenberg S, et al. Transcatheter mitral valve-in-valve implantation in patients with degenerated bioprostheses. JACC Cardiovasc Interv. 2012;5:341-9. 5. Seiffert M, Baldus S, Conradi L, Koschyk D, Schirmer J, Meinertz T, et al. Simultaneous transcatheter aortic and mitral valve-in-valve implantation in a patient with degenerated bioprostheses and high surgical risk. Thorac Cardiovasc Surg. 2011;59:490-2.
Total artificial heart for patients with allograft failure Mohammed A. Quader, MD,a Daniel Tang, MD,a Gundars Katlaps, MD,a Keyur B. Shah, MD,b and Vigneshwar Kasirajan, MD,a Richmond, Va
Allograft failure may limit survival after heart transplant (HTx). For many patients with primary graft failure or chronic allograft vasculopathy retransplantation is the only treatment option. However, presensitization and limited donor heart availability may prolong wait times. From the Division of Cardiothoracic Surgery,a and Division of Cardiology,b Virginia Commonwealth University Health System, Richmond, Va. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication April 18, 2012; revisions received July 3, 2012; accepted for publication Oct 26, 2012; available ahead of print Nov 23, 2012. Address for reprints: Mohammed A. Quader, MD, Division of Cardiothoracic Surgery, PO Box 980068, Richmond, VA 23298-0068 (E-mail: [email protected]). J Thorac Cardiovasc Surg 2013;145:e21-3 0022-5223/$0.00 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2012.10.050
Because allograft failure frequently manifests as biventricular dysfunction, left ventricular assist devices (LVADs) often provide inadequate support. Biventricular assist device support has been used successfully in the past,1 but remains challenging due to anatomic constraints with small ventricles. The total artificial heart (TAH) (Syncardia, Inc, Tucson, Ariz) overcomes these limitations and can successfully support patients with allograft failure.2 We present our experience with 5 patients who presented with allograft failure and were supported with a TAH. CLINICAL SUMMARY Patient characteristics are described in Table 1. The patients’ ages ranged from 19 to 61 years, and 3 were men. The time from transplantation to TAH placement was
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Transapical implantation of an Edwards Sapien valve into a failed prosthetic mitral valve 3 years after a transapical aortic valve implantation Siyamek Neragi-Miandoab, MD, PhD,a Friedrich W. Mohr, MD,b Michael A. Borger, MD,b and David M. Holzhey, MD,b New York, NY, and Leipzig, Germany Bioprosthetic valves are being used with increasing frequency for valve replacement surgery, even in young patients. Because of this, an increasing number of patients From the Department of Cardiovascular and Thoracic Surgery,a Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY; and the Department of Cardiac Surgery,b Heart Center Leipzig, Leipzig, Germany. Disclosures: D.M.H. and B.A.M. have received honoraria from Edwards Lifesciences LLC for lectures and consulting services. All other authors have nothing to disclose with regard to commercial support. Sapien valves are manufactured by Edwards Lifesciences LLC, Irvine, Calif. Received for publication Sept 23, 2012; accepted for publication Oct 2, 2012; available ahead of print Oct 29, 2012. Address for reprints: David M. Holzhey, MD, Heart Center Leipzig, 04289 Leipzig, Germany (E-mail: [email protected]). J Thorac Cardiovasc Surg 2013;145:e19-21 0022-5223/$36.00 Copyright Ó 2013 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2012.10.010
are expected to present with structural bioprosthetic valve degeneration in coming years. The operative mortality and morbidity associated with reoperative mitral valve (MV) surgery remains higher than for first-time operations. Transapical transcatheter mitral valve-in-valve (MVinV) implantation might offer an alternate and safer approach for high-risk patients who are not suitable candidates for surgical MV replacement. A transcatheter valve-in-valve approach has already been shown to be feasible and safe in patients with failed aortic valve (AV) bioprostheses. Moreover, simultaneous transapical transcatheter AV and MV replacement in high-risk patients with previous MV bioprostheses has been reported.1 We report here the case of a patient who underwent 2 separate transapical valvular operations 3 years apart, including an MVinV procedure.
FIGURE 1. A, Adhesions between the apex of the heart and the chest wall. These adhesions did not present a significant challenge for the reoperative transapical approach. B, Measurement of mitral valve bioprosthesis inner diameter in computed tomographic scan. C, Preoperative echocardiogram showing severe stenosis of the mitral bioprosthesis. D, Echocardiogram showing the severity of degenerative changes on the bioprosthesis.
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Case Reports
FIGURE 2. A and B, Implantation of the balloon-expandable valve into the degenerated prosthetic valve in the mitral position. C, Postoperative appearance of deployed valves on chest radiography, with the previous valve in the aortic position and the recent valve in the mitral position. D, Postoperative echocardiogram demonstrating adequate opening of the new mitral prosthesis.
CLINICAL SUMMARY The patient was an 81-year-old white woman who had originally received an MV bioprosthesis (Hancock II, size 29 mm; Medtronic, Inc, Minneapolis, Minn) in 2005 through a standard sternotomy approach. The patient had symptomatic AV stenosis, prompting transapical aortic valve implantation (TA-AVI) with a Sapien valve (Edwards Lifesciences, Irvine, Calif) in 2009. Since then, she had been doing well until a few months before the index visit, when she came to the hospital with progressive symptoms of heart failure (New York Heart Association III or IV functional class). The workup demonstrated degenerative changes on her mitral bioprosthesis causing severe stenosis and secondary pulmonary hypertension (systolic pulmonary arterial pressure, 50-60 mm Hg). A transthoracic echocardiogram demonstrated an enlarged left atrium (58 3 57 mm) and a severely stenotic mitral bioprosthesis, with peak and mean gradients of 34 and 16 mm Hg, respectively. The MV orifice area was 0.8 cm2, and prosthetic valve cusps were severely calcified and immobile (Figure 1). The left ventricular ejection fraction was 40%. After a multidisciplinary discussion with consideration of the patient’s age, operative risk, and multiple comorbidities (including diabetes, hyperthyroidism, systemic and pulmonary hypertension, and previous stroke), the decision was made to perform a transapical MVinV procedure. e20
After induction of general anesthesia, the previous transapical access scar that had been used for TA-AVI was identified and exposed. After placement of 2 purse-string sutures (2-0 Prolene with dissolvable pledgets; Ethicon, Inc, Somerville, NJ), a guide wire was inserted and passed through the MV prosthesis. An Edwards SAPIEN 29-mm valve was crimped and loaded onto the delivery system and then implanted under fluoroscopic and transesophageal echocardiographic guidance (Figure 2). At the end of the procedure, the mitral stenosis had resolved, with a transvalvular gradient of 3 to 4 mm Hg. The patient was extubated a few hours after the procedure. The postoperative course was unremarkable, and the patient was discharged from the hospital on postoperative day 3. DISCUSSION Few studies currently exist of patients who have undergone a transcatheter MVinV procedure. To the best of our knowledge, we present the first case of a patient undergoing an MVinV procedure through a second consecutive transapical approach after previous TA-AVI. With an aging patient population in Europe and North America, combined with an ever increasing proportion of patients undergoing biologic valve replacement surgery, the need for reoperative valvular procedures may be increasing. If patients are young or lacking comorbidities, the standard approach
The Journal of Thoracic and Cardiovascular Surgery c February 2013
Case Reports
remains conventional surgical reoperation. High-risk patients, however, may not tolerate reoperations. The introduction of catheter-based valve implantation has produced a new option of a valve-in-valve approach to failing bioprostheses.2 Without the anatomic difficulties associated with transcutaneous valve implantation in a native mitral annulus or a preexisting mitral annuloplasty ring, performance of the MVinV procedure is relatively straightforward because of the circular bioprosthesis sewing ring, which serves as an excellent landing zone for the transcutaneous valve stent. Cheung and colleagues3 reported a small series of 11 patients (mean Society of Thoracic Surgeons score of 16%) with symptomatic mitral prosthetic valve dysfunction who underwent transapical MVinV. The success rate was 100%, with no 30-day mortality. Nine patients were alive and in New York Heart Association class I or II at a median follow-up of 357 days.3 Similarly, Seiffert and associates4 reported on 6 high-risk patients (EuroSCORE of 33%) who underwent MVinV. Implantation was successful in all patients, with reduction of the transvalvular gradients and median regurgitation from grade 3 to 0. All patients in these studies received a balloon-expandable bovine SAPIEN valve. Despite the fact that Seiffert and associates4 reported postoperative complications in 3 patients, this approach remains acceptable for high-risk patients with a failed bioprosthetic MV. As this case report demonstrates, the transapical method allows access to the AV and MV,
even during the same procedure for patients at very high risk requiring reoperative double valve replacement.5 The unique aspect of this case report is that the patient had undergone a previous TA-AVI procedure. Despite the fact that the apex had previously been used for a TA-AVI operation, we did not have any difficulties with mobilization or cannulation of the apex during the MVinV procedure. With a growing need for reoperative MV replacement for bioprosthetic structural valve deterioration, transcatheter MVinV placement has become as an alternate option. Although the evidence for this approach is limited to a few case reports and small case series, it appears to be a feasible, safe, and promising approach in a select patient population. References 1. Holzhey DM, Schuler G, Mohr FW, Mukherjee C. Transapical double valve implantation plus percutaneous revascularization as a bailout for a high-risk patient. J Thorac Cardiovasc Surg. 2012;144:508-10. 2. Nu~nez-Gil IJ, Gonc¸alves A, Rodrıguez E, Cobiella J, Marcos-Alberca P, Maroto L, et al. Transapical mitral valve-in-valve implantation: a novel approach guided by three-dimensional transoesophageal echocardiography. Eur J Echocardiogr. 2011;12:335-7. 3. Cheung AW, Gurvitch R, Ye J, Wood D, Lichtenstein SV, Thompson C, et al. Transcatheter transapical mitral valve-in-valve implantations for a failed bioprosthesis: a case series. J Thorac Cardiovasc Surg. 2011;141:711-5. 4. Seiffert M, Conradi L, Baldus S, Schirmer J, Knap M, Blankenberg S, et al. Transcatheter mitral valve-in-valve implantation in patients with degenerated bioprostheses. JACC Cardiovasc Interv. 2012;5:341-9. 5. Seiffert M, Baldus S, Conradi L, Koschyk D, Schirmer J, Meinertz T, et al. Simultaneous transcatheter aortic and mitral valve-in-valve implantation in a patient with degenerated bioprostheses and high surgical risk. Thorac Cardiovasc Surg. 2011;59:490-2.
Total artificial heart for patients with allograft failure Mohammed A. Quader, MD,a Daniel Tang, MD,a Gundars Katlaps, MD,a Keyur B. Shah, MD,b and Vigneshwar Kasirajan, MD,a Richmond, Va
Allograft failure may limit survival after heart transplant (HTx). For many patients with primary graft failure or chronic allograft vasculopathy retransplantation is the only treatment option. However, presensitization and limited donor heart availability may prolong wait times. From the Division of Cardiothoracic Surgery,a and Division of Cardiology,b Virginia Commonwealth University Health System, Richmond, Va. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication April 18, 2012; revisions received July 3, 2012; accepted for publication Oct 26, 2012; available ahead of print Nov 23, 2012. Address for reprints: Mohammed A. Quader, MD, Division of Cardiothoracic Surgery, PO Box 980068, Richmond, VA 23298-0068 (E-mail: [email protected]). J Thorac Cardiovasc Surg 2013;145:e21-3 0022-5223/$0.00 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2012.10.050
Because allograft failure frequently manifests as biventricular dysfunction, left ventricular assist devices (LVADs) often provide inadequate support. Biventricular assist device support has been used successfully in the past,1 but remains challenging due to anatomic constraints with small ventricles. The total artificial heart (TAH) (Syncardia, Inc, Tucson, Ariz) overcomes these limitations and can successfully support patients with allograft failure.2 We present our experience with 5 patients who presented with allograft failure and were supported with a TAH. CLINICAL SUMMARY Patient characteristics are described in Table 1. The patients’ ages ranged from 19 to 61 years, and 3 were men. The time from transplantation to TAH placement was
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