Author + information
- Received August 31, 2017
- Accepted September 13, 2017
- Published online February 5, 2018.
- Konstantinos Toutouzas, MD, PhDa,∗ (, )
- Vasilis Lozos, MDb,
- George Oikonomou, MDa,
- Constantina Aggeli, MD, PhDa,
- George Latsios, MD, PhDa,
- Maria Drakopoulou, MD, PhDa,
- Andreas Synetos, MD, PhDa,
- George Trantalis, MDa,
- Konstantinos Stathogiannis, MDa,
- Konstantinos Triantafillou, MDb and
- Dimitris Tousoulis, MD, PhDa
- aFirst Department of Cardiology, Hippokration Hospital, University of Athens, Athens, Greece
- bDepartment of Cardiothoracic Surgery, Hippokration Hospital, University of Athens, Athens, Greece
- ↵∗Address for correspondence:
Dr. Konstantinos Toutouzas, 24 Karaoli and Dimitrioustr, 15562, Holargos, Athens, Greece.
Transcatheter valve-in-ring procedure has shown in a number of small case series to be feasible, safe, and able to offer short-term clinical and hemodynamic improvement in selected high-risk patients after failed surgical mitral annuloplasty ring repair (1).
Hereby, we report a case of a 70-year-old man who was admitted due to progressively increasing dyspnea (New York Heart Association functional class III). The patient had a background of severe degenerative mitral regurgitation secondary to ruptured tendinous cord of the anterior mitral leaflet, for which he underwent complex mitral valve reconstruction including annuloplasty with a 25-mm circular flexible Duran ring (Medtronic, Minneapolis, Minnesota), implantation of the ruptured tendinous cord into the anterior papillary muscle, and placement of new synthetic chordae tendineae. At the same time, he received a prosthetic metallic aortic valve (ATS Open Pivot Heart Valve 25 mm, ATS Medical, Inc. Minneapolis, Minnesota) due to severe aortic insufficiency. On admission he was found to have normocytic anemia (hemoglobin = 7.1 g/dl) accompanied by elevated indirect bilirubin and Lactate dehydrogenase levels, suggestive of hemolytic anemia.
Transthoracic echocardiography and transesophageal echocardiography (TEE) studies revealed moderate to severe para-ring intravalvular mitral regurgitation due to partial dehiscence of the annuloplasty ring in the anterior mitral annulus (Figures 1A to 1C, Online Videos 1 and 2) and severe transvalvular mitral regurgitation due to malcoaptation of the valve leaflets (Figure 1B, Online Video 1). Due to the high surgical risk of the patient and the favorable characteristics of the annuloplasty ring (flexible with circular geometry), the Heart Team decided to proceed to a transcatheter valve-in-ring procedure. In case of inefficacious sealing, decision was made to implant an Amplatzer occluder device (St. Jude Medical, St. Paul, Minnesota) in the perivalvular space of ring dehiscence.
The patient underwent a transapical approach under fluoroscopic and TEE guidance. A 29-mm SAPIEN XT prosthesis was mounted upside down on a Novaflex catheter (Edwards Lifesciences, Irvine, California) in the retrograde orientation. Then, the SAPIEN XT valve was successfully placed within the Duran ring (Figure 2A). The positioning was carefully checked by fluoroscopy and TEE and optimized by slow balloon inflation under rapid ventricular pacing. Attempts were made to place the prosthesis one-third in the left atrium and two-thirds in the left ventricle so as to cover the annuloplasty ring with the basal skirt of the SAPIEN valve to reduce the risk of periprosthetic leak and at the same time avoid obstructing the left ventricular outflow tract (LVOT) in the presence of a mechanical aortic valve (Figure 2B).
The prosthetic mitral valve was in situ and well seated within the mitral ring, while it was functioning properly with only mild perivalvular regurgitation (Figure 3A, Online Video 3). The deformability of the flexible Duran ring made it possible to obtain a more circular configuration allowing for good application of the prosthesis (Figure 3B, Online Video 4). Furthermore, effective reduction of the para-ring leak was achieved at the leaflet level by proper sealing of the native anterior mitral leaflet around the prosthesis (Figure 3B). Mean gradient of the prosthetic mitral valve was 6 mm Hg and there were no signs of dynamic LVOT obstruction.
The patient’s dyspnea had substantially improved and signs of hemolysis had resolved during hospitalization. He was discharged at day 5 after an uneventful recovery period and at 1 month follow-up the patient was experiencing only mild symptoms during his ordinary physical activity (New York Heart Association functional class II) with no recurrence of hemolysis. Furthermore, at 30-day follow-up, transthoracic echocardiography demonstrated good function of the SAPIEN valve, with no obstruction of the LVOT (Figures 4A and 4B).
Dr. Toutouzas has served as a proctor for the Medtronic CoreValve. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 31, 2017.
- Accepted September 13, 2017.
- 2018 American College of Cardiology Foundation