Author + information
- Received July 27, 2017
- Revision received August 17, 2017
- Accepted August 18, 2017
- Published online October 2, 2017.
- Tiberio M. Frisoli, MDa,∗ (, )
- Dee Dee Wang, MDa,
- Marvin Eng, MDa,
- William W. O’Neilla,
- Gaetano Paone, MDb and
- Adam B. Greenbaum, MDa
- aCenter for Structural Heart Disease, Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan
- bDivision of Cardiac Surgery, Heart and Vascular Institute, Henry Ford Hospital, Detroit, Michigan
- ↵∗Address for correspondence:
Dr. Tiberio M. Frisoli, Heart and Vascular Institute, Henry Ford Hospital, K14, 2799 West Grand Boulevard, Detroit, Michigan 48202.
A 60-year-old man who underwent prior surgical repair of severe mitral regurgitation with a 28-mm Sorin 3-dimensional Memo complete semi-rigid annuloplasty ring (Sorin Group, Arvada, Colorado) developed symptomatic severe functional mitral stenosis (transmitral mean gradient: 10.7 mm Hg at a heart rate of 90 beats/min on echocardiogram). By multidisciplinary review, he was felt to be an appropriate candidate for transcatheter mitral valve replacement given multiple comorbidities.
Computed tomography scan showed mitral ring internal diameters of 23.3 mm × 23.3 mm, yet the manufacturer’s specifications suggest an intercommisural distance of 25.9 mm. During transcatheter mitral valve-in-ring (TMViR) intervention, a 23-mm balloon was inflated within the surgical ring for sizing purposes with a slight waist appearance (Figure 1A). A 26-mm Edwards Sapien 3 valve (Edwards Lifesciences, Irvine, California) was deployed inside the ring, with 2 ml less than nominal volume (Figure 1B). To ensure stability, the balloon was advanced and, with an additional 2 ml in the balloon, reinflated to flare the ventricular side of the valve (Figure 1C). Transesophageal echocardiography now revealed severe paravalvular leak (PVL). Post-dilatation with a 24-mm noncompliant balloon was performed (Online Video 1) in the hope of reducing the PVL, which was felt to be located between the transcatheter valve and surgical ring. However, the severe PVL was unchanged and now noted by transesophageal echocardiography (TEE) to in fact be outside the surgical ring (Figure 2). Fluoroscopic comparison of the ring before and after valve deployment illustrated a fracture in the mitral ring (Figure 3, Online Videos 2A and 2B). Over a veno-arterial rail, 3 occluders (two 6/4 Amplatzer Duct Occluder II followed by one 14-mm Amplatzer Vascular Plug II occluder [both St. Jude Medical, St. Paul, Minnesota]) were deployed, reducing PVL to trivial (Online Videos 3A and 3B). The 3 occluder devices can be seen adjacent to the fractured segment of the mitral ring (Online Video 4). Left atrial peak pressure was reduced from 48 to 27 mm Hg (Figure 4).
TEE evaluation pre-TMViR/PVL repair as compared to post-TMViR/PVL repair revealed the following: pulmonary vein pattern changed from systolic flow reversal to impaired relaxation pattern; mean transmitral gradient by TEE improved from 6.9 mm Hg to 4.7 mm Hg.
Follow-up echocardiography 1 and 10 days post-procedure confirmed normal TMV function and trivial residual mitral regurgitation. The patient was discharged on post-procedure day 28, but 2 months thereafter was admitted with fever and septic infection and subsequently passed away.
To our knowledge, this is the first report of a fractured mitral annuloplasty ring with resultant annular tear and severe PVL during transcatheter valve intervention. Knowledge that certain rings may unintentionally be fractured, and that tearing of the ring from the annulus, as is likely what happened in this case, may occur during TMV replacement warrants awareness and caution.
As is not uncommon, there was discrepancy between the manufacturer’s listed intercommissural ring distance (25.9 mm) and that which was calculated by computed tomography (23.3 mm). In retrospective review of images, it appears that the ring fracture occurred during initial valve deployment and that the PVL was located outside the surgical ring, explaining the lack of benefit from post-dilation with the 24-mm noncompliant balloon. Whereas use of a 23-mm transcatheter valve may have avoided the ring tear, placement of a circular 23-mm transcatheter valve in a semirigid noncircular ring of this listed size may have yielded valve embolization or regurgitation between the valve and ring. Resolving size discrepancies between computed tomography and manufacturer can be difficult. The degree of oversizing required to secure a transcatheter heart valve is debatable; for valve-in-valve, a minimum 2- to 3-mm oversize above the true internal diameter is recommended to achieve a good result (1). It is felt that valve-in-ring interventions may require similar oversizing. Use of a sizing balloon can be helpful in making final decisions on valve size choice. Nonetheless, knowledge of the potential for ring fracture (particularly during oversized valve-in-ring intervention) and competency and experience with PVL repair are important for the operator who attempts transcatheter interventions similar to the one herein described, as this skill may prove urgent and necessary to manage complications.
Alternatively, intentional ring fracturing may have clinical application if desired, such as allowing for enlargement of the mitral annular area and perhaps improved hemodynamic profiles in certain circumstances. Surgical MV repair, which often involves use of a smaller down-sizing annuloplasty ring, has been associated with elevated transmitral gradients (2,3), which has been shown to result in lower metabolic equivalent score on functional testing at mean 4.2 years following surgery (4). Similar to the growing and successful experience with intentional bioprosthetic aortic valve fracturing during transcatheter aortic valve replacement (5), maybe similar advantages can be achieved with certain mitral rings if balloon dilatation is performed with a balloon-ring size ratio such that there is fracturing of the ring without tearing of the annulus.
Bench testing of the various rigid and semirigid rings may prove helpful prior to attempted TMViR and if intentional fracturing is contemplated.
Dr. Frisoli is a consultant for Edwards Lifesciences and Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 27, 2017.
- Revision received August 17, 2017.
- Accepted August 18, 2017.
- 2017 American College of Cardiology Foundation
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