- Email: [email protected]
Transcatheter Lotus Valve Implantation in a Stenotic Mitral Valve
JACC: CARDIOVASCULAR INTERVENTIONS
VOL.
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
-, NO. -, 2016
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcin.2016.08.026
IMAGES IN INTERVENTION
Transcatheter Lotus Valve Implantation in a Stenotic Mitral Valve Ben Ren, MD, PHD,a Zouhair Rahhab, MD,a Jan von der Thüsen, MD,b Joost Daemen, MD, PHD,a Marcel L. Geleijnse, MD, PHD,a Peter P.T. de Jaegere, MD, PHD,a Arie Pieter Kappetein, MD, PHD,c Nicolas M. Van Mieghem, MD, PHDa
A
75-year-old woman with degenerative mitral
Massachusetts).
stenosis and a prior aortic bioprosthesis was
under general anesthesia, supported with fluoros-
The
procedure
was
performed
referred for potential valvular intervention.
copy and transesophageal echocardiography. A cere-
She had been symptomatic (New York Heart Associa-
bral embolic protection device was deployed in the
tion functional classes III to IV), with a history of syn-
brachiocephalic trunk and left common carotid artery
cope, chronic obstructive pulmonary disease, latent
prior to the valve implantation to collect potential
tuberculosis, and thrombocytopenia. She was consid-
debris released during the procedure (Figure 1D).
ered inoperable because of excessive comorbidities
A coronary guidewire in the left circumflex coronary
(Society of Thoracic Surgeons score 9.5%) by the heart
artery served as a fluoroscopic landmark for Lotus
echocardiography
valve positioning (Figure 1E). Through a left lateral
revealed a severely calcified mitral annulus with a
minithoracotomy, the Lotus valve was smoothly
transvalvular mean pressure gradient of 13 mm Hg.
delivered into the mitral annulus and gradually
Transesophageal
a
deployed (Online Video 4). After 1 position adjust-
heavily calcified mitral apparatus, including the chor-
ment, the valve was released somewhat higher above
dae tendineae, with an immobile posterior leaflet
the mitral annulus (Figure 1F) to avoid interference
(Figure 1A, Online Video 1). The mitral orifice area
with the left ventricular outflow tract and aortic bio-
was 0.9 cm 2 by 3-dimensional planimetry. The Wil-
prosthesis. The transvalvular mean pressure gradient
kins score was 10, ruling out safe percutaneous
was 2 mm Hg, with mild paravalvular leakage
balloon mitral valvuloplasty (1). Extensively calcified
(Figure 1G). Debris was captured in the embolic pro-
mitral annulus and leaflets were also seen on multi-
tection device (Figure 1H) and consisted of platelet
slice computed tomography. The mitral annular area
aggregates, endothelium, fragments of connective
was 526 mm 2, and the perimeter was 84 mm, with a
tissue, myxoid stroma, and myocardium (Figure 1I).
team
consensus.
Transthoracic
echocardiography
confirmed
minimum diameter of 22 mm and a maximal diameter
As previously reported, transcatheter mitral valve
of 31 mm (Figure 1B). On the basis of the findings of
implantation in a native calcified mitral valve and
multislice computed tomography, an in vitro valve
degenerated bioprosthesis is feasible with balloon-
implantation was conducted in a reconstructed
expandable valves (2,3). In our case, considering the
3-dimensional printed model (Figure 1C, Online
sizing and repositionable and retrievable character-
Videos 2 and 3), which confirmed the suitability of
istics of the prosthesis, the mechanically expanded
transapical transcatheter mitral valve implantation
Lotus valve was chosen, also avoiding the fast pacing
with a 27-mm Lotus valve (Boston Scientific, Natick,
required in balloon-expandable valve implantation.
From the aDepartment of Cardiology, Thoraxcenter; bDepartment of Pathology; and the cDepartment of Cardiothoracic Surgery, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Ren and Rahhab contributed equally to this work. Manuscript received July 25, 2016; accepted August 11, 2016.
e2
Ren et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2016 - 2016:e-–-
Lotus Valve in Stenotic Mitral Valve
F I G U R E 1 Multi-Imaging Modality in Pre-Procedural Work Up and Intra-Procedural Monitoring and Assessment
(A) 2-dimensional (2D) transesophageal echocardiography (TEE) showing a heavily calcified mitral apparatus, including the chordae tendineae (arrows point to the calcification) (left); 3-dimensional (3D) TEE showing calcified mitral annulus (MA) and leaflets, with a severely stenotic orifice opening in diastole (right). See Online Video 1. (B) Multislice computed tomography showing severely calcified MA (left) with its dimensions (right). (C) In vitro Lotus valve implantation in a reconstructed 3D printed model based on multislice computed tomographic measurements. See Online Videos 2 and 3. (D) A Sentinel cerebral embolic protection device was placed in the brachiocephalic artery (proximal) and left common carotid artery (distal) (arrows point to the filters implanted). (E) The circumflex coronary artery was visualized with a wire on fluoroscopy (arrow) and used as a landmark for valve positioning. (F) Final release of the Lotus valve shown on fluoroscopy (left); the valve was intentionally released a little higher than the mitral annulus, as shown with TEE (right) to avoid interference to the left ventricular outflow tract and aortic bioprosthesis. See Online Video 4. (G) 3D (left) and 2D (right) color TEE showing mild eccentric paravalvular leakage. (H) Cerebral embolic protection device after retrieval and (I) histopathologic coupe of fragments of myocardium captured.
Continued on the next page
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2016
Ren et al.
- 2016:e-–-
Lotus Valve in Stenotic Mitral Valve
F I G U R E 1 Continued
Considering the severity of mitral apparatus calcification, an embolic protection device was implanted
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
to prevent potential cerebral complications. The im-
Nicolas M. Van Mieghem, Department of Interventional
plantation process evolved smoothly, with a satis-
Cardiology, Thoraxcenter, Erasmus MC, Office Building
factory result, showing that the Lotus valve is feasible
171, ’s Gravendijkwal 230, Rotterdam 3015 CE, the
for this procedure.
Netherlands. E-mail: [email protected].
REFERENCES 1. Nobuyoshi M, Arita T, Shirai S, et al. Percutaneous balloon mitral valvuloplasty: a review. Circulation 2009;119:e211–9. 2. Ribeiro HB, Doyle D, Urena M, et al. Transapical mitral implantation of a balloon-expandable valve in native mitral valve stenosis in a patient with
previous transcatheter aortic valve replacement. J Am Coll Cardiol Intv 2014;7:e137–9.
KEY WORDS mitral valve, transcatheter
3. Seiffert M, Conradi L, Baldus S, et al. Trans-
implantation
catheter mitral valve-in-valve implantation in patients with degenerated bioprostheses. J Am Coll Cardiol Intv 2012;5:341–9.
A PPE NDI X For supplemental videos, please see the online version of this article.
e3
VOL.
ª 2016 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
-, NO. -, 2016
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER
http://dx.doi.org/10.1016/j.jcin.2016.08.026
IMAGES IN INTERVENTION
Transcatheter Lotus Valve Implantation in a Stenotic Mitral Valve Ben Ren, MD, PHD,a Zouhair Rahhab, MD,a Jan von der Thüsen, MD,b Joost Daemen, MD, PHD,a Marcel L. Geleijnse, MD, PHD,a Peter P.T. de Jaegere, MD, PHD,a Arie Pieter Kappetein, MD, PHD,c Nicolas M. Van Mieghem, MD, PHDa
A
75-year-old woman with degenerative mitral
Massachusetts).
stenosis and a prior aortic bioprosthesis was
under general anesthesia, supported with fluoros-
The
procedure
was
performed
referred for potential valvular intervention.
copy and transesophageal echocardiography. A cere-
She had been symptomatic (New York Heart Associa-
bral embolic protection device was deployed in the
tion functional classes III to IV), with a history of syn-
brachiocephalic trunk and left common carotid artery
cope, chronic obstructive pulmonary disease, latent
prior to the valve implantation to collect potential
tuberculosis, and thrombocytopenia. She was consid-
debris released during the procedure (Figure 1D).
ered inoperable because of excessive comorbidities
A coronary guidewire in the left circumflex coronary
(Society of Thoracic Surgeons score 9.5%) by the heart
artery served as a fluoroscopic landmark for Lotus
echocardiography
valve positioning (Figure 1E). Through a left lateral
revealed a severely calcified mitral annulus with a
minithoracotomy, the Lotus valve was smoothly
transvalvular mean pressure gradient of 13 mm Hg.
delivered into the mitral annulus and gradually
Transesophageal
a
deployed (Online Video 4). After 1 position adjust-
heavily calcified mitral apparatus, including the chor-
ment, the valve was released somewhat higher above
dae tendineae, with an immobile posterior leaflet
the mitral annulus (Figure 1F) to avoid interference
(Figure 1A, Online Video 1). The mitral orifice area
with the left ventricular outflow tract and aortic bio-
was 0.9 cm 2 by 3-dimensional planimetry. The Wil-
prosthesis. The transvalvular mean pressure gradient
kins score was 10, ruling out safe percutaneous
was 2 mm Hg, with mild paravalvular leakage
balloon mitral valvuloplasty (1). Extensively calcified
(Figure 1G). Debris was captured in the embolic pro-
mitral annulus and leaflets were also seen on multi-
tection device (Figure 1H) and consisted of platelet
slice computed tomography. The mitral annular area
aggregates, endothelium, fragments of connective
was 526 mm 2, and the perimeter was 84 mm, with a
tissue, myxoid stroma, and myocardium (Figure 1I).
team
consensus.
Transthoracic
echocardiography
confirmed
minimum diameter of 22 mm and a maximal diameter
As previously reported, transcatheter mitral valve
of 31 mm (Figure 1B). On the basis of the findings of
implantation in a native calcified mitral valve and
multislice computed tomography, an in vitro valve
degenerated bioprosthesis is feasible with balloon-
implantation was conducted in a reconstructed
expandable valves (2,3). In our case, considering the
3-dimensional printed model (Figure 1C, Online
sizing and repositionable and retrievable character-
Videos 2 and 3), which confirmed the suitability of
istics of the prosthesis, the mechanically expanded
transapical transcatheter mitral valve implantation
Lotus valve was chosen, also avoiding the fast pacing
with a 27-mm Lotus valve (Boston Scientific, Natick,
required in balloon-expandable valve implantation.
From the aDepartment of Cardiology, Thoraxcenter; bDepartment of Pathology; and the cDepartment of Cardiothoracic Surgery, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Ren and Rahhab contributed equally to this work. Manuscript received July 25, 2016; accepted August 11, 2016.
e2
Ren et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2016 - 2016:e-–-
Lotus Valve in Stenotic Mitral Valve
F I G U R E 1 Multi-Imaging Modality in Pre-Procedural Work Up and Intra-Procedural Monitoring and Assessment
(A) 2-dimensional (2D) transesophageal echocardiography (TEE) showing a heavily calcified mitral apparatus, including the chordae tendineae (arrows point to the calcification) (left); 3-dimensional (3D) TEE showing calcified mitral annulus (MA) and leaflets, with a severely stenotic orifice opening in diastole (right). See Online Video 1. (B) Multislice computed tomography showing severely calcified MA (left) with its dimensions (right). (C) In vitro Lotus valve implantation in a reconstructed 3D printed model based on multislice computed tomographic measurements. See Online Videos 2 and 3. (D) A Sentinel cerebral embolic protection device was placed in the brachiocephalic artery (proximal) and left common carotid artery (distal) (arrows point to the filters implanted). (E) The circumflex coronary artery was visualized with a wire on fluoroscopy (arrow) and used as a landmark for valve positioning. (F) Final release of the Lotus valve shown on fluoroscopy (left); the valve was intentionally released a little higher than the mitral annulus, as shown with TEE (right) to avoid interference to the left ventricular outflow tract and aortic bioprosthesis. See Online Video 4. (G) 3D (left) and 2D (right) color TEE showing mild eccentric paravalvular leakage. (H) Cerebral embolic protection device after retrieval and (I) histopathologic coupe of fragments of myocardium captured.
Continued on the next page
JACC: CARDIOVASCULAR INTERVENTIONS VOL.
-, NO. -, 2016
Ren et al.
- 2016:e-–-
Lotus Valve in Stenotic Mitral Valve
F I G U R E 1 Continued
Considering the severity of mitral apparatus calcification, an embolic protection device was implanted
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
to prevent potential cerebral complications. The im-
Nicolas M. Van Mieghem, Department of Interventional
plantation process evolved smoothly, with a satis-
Cardiology, Thoraxcenter, Erasmus MC, Office Building
factory result, showing that the Lotus valve is feasible
171, ’s Gravendijkwal 230, Rotterdam 3015 CE, the
for this procedure.
Netherlands. E-mail: [email protected].
REFERENCES 1. Nobuyoshi M, Arita T, Shirai S, et al. Percutaneous balloon mitral valvuloplasty: a review. Circulation 2009;119:e211–9. 2. Ribeiro HB, Doyle D, Urena M, et al. Transapical mitral implantation of a balloon-expandable valve in native mitral valve stenosis in a patient with
previous transcatheter aortic valve replacement. J Am Coll Cardiol Intv 2014;7:e137–9.
KEY WORDS mitral valve, transcatheter
3. Seiffert M, Conradi L, Baldus S, et al. Trans-
implantation
catheter mitral valve-in-valve implantation in patients with degenerated bioprostheses. J Am Coll Cardiol Intv 2012;5:341–9.
A PPE NDI X For supplemental videos, please see the online version of this article.
e3