Transcatheter Mitral Valve in Valve Replacement in a transeptal approach.


Operators: Dr Eftychiou, Dr Mitsis, Dr Avraamides, Dr Spargias
Echocardiographist: Dr Rotos, Dr Avraamide K, Dr Simamonian, Dr Ioannides, Dr Chrysocheris
Cardiac Anaesthetists: Dr Hadzigeorgiou, Dr Kornioti


Δημοσίευση 09/03/2021

Περιγραφή: This is the case of a 73 year old female patient admitted to the Cardiology Department of Nicosia General Hospital with acute pulmonary oedema due to severe mitral valve bioprosthetic stenosis. She had a history of MV Endocarditis and MV Replacement 5 years ago with a #25mm Sorin Pericarbone More and LV pseudoaneurysm treated with a patch (There was a 3x4cm cavity in the annulus of the posterior leaflet of the MV with thin walls bulging out of the LV wall due to a contained rupture of a mycotic aneurysm). Her medical history also included IDDM, HTN, severe COPD, Ca Breast treated with radiotherapy and chronic renal failure. She had a high risk for redo MVR with Euroscore II: 21.9% and STS: 26.6%.

Her TOE showed a degenerated MV with thickened valve leaflets and restricted motion. Severe stenosis with MVA<1cm2 and Mean MV gradient: 20mmHg. Moderate to severe TR with RVSP: 80mmHg.

Her left heart catheterization showed:
Left and right heart pressures: LV: 120/14mmHg, Aorta: 120/70mmHg. PA: 93/32mmHg (mean: 60mmHg), PCW (mean): 35mmHg, RV: 78/2mmHg, RA (mean): 5mmHg.
The coronaries were atheromatous without significant disease. The RCA is the dominant artery.
Severe MV bioprostheses stenosis with a mean gr: 21mmHg

CT measurements on Osirix MD software: MV annulus diameter: 20x21mm, MV annulus area: 337mm2, MV annulus perimeter: 65.4mm. Mitroaortic Angle: 125 degrees.
Based on CT measurements and using the 3D software Mimics Enlight we decided that we could implant a 23mm Sapien 3 with a low risk of LVOT obstruction and a predicted NeoLVOT area of 368mm2.

A 6F sheath was placed in the LFV and a temporary pacemaker was placed in the RV. A 6F sheath was then placed in the RFV and a Proglide was preplaced for haemostasis. A 0.035 guide wire was placed in the SVC to exchange to an 8F SLO sheath loaded with a BRK needle and a Safe Sept transeptal guide wire. A transeptal puncture using the BRK needle was followed by advancement of the SLO Fast Cath in the LA. Anticoagulation was achieved with a total 7000 IU of heparin given IV. The BRK needle and the dilator were removed, and an Amplatz Extra Stiff wire was placed in the LUPV. The SLO Fast Cath was removed and a MP1 catheter was placed in the LUPV which was then replaced by an 8.5F Agilis steering catheter to facilitate the crossing of the MV. A pigtail was placed in the LV through the Agilis and a Lunderquist was placed in the LV apex. The Pigtail was removed and septostomy with a Medtronic Admiral Extreme balloon 9.0 x 40mm was performed. Both the balloon and the Agilis were removed and the 16F Edwards e-sheath was placed through the RFV.
A 23mm Sapien 3 valve with 3ml of added volume was deployed in rapid pacing (120b/min) and in an 80/20 (LV/LA) position with an excellent result.
The MV mean gr was 14mmHg on echo before the procedure and after the placement of the Sapien 3 was 5mmHg while the LVOT mean gr was <7mmHg.
The sheath was removed and RFV hemostasis was achieved with the proglide. The LFV sheath was also removed in the cath lab with manual compression.

Συμπέρασμα: A degenerated bioprosthetic Mitral Valve can be treated with a transcatheter method using a balloon expandable valve through a Femoral vein and a transeptal approach.
Careful planning is needed to decide the appropriate valve to be used and to estimate the risk of LVOT obstruction.

Φαρμακευτική αγωγή: Warfarin for 6 months

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