Author + information
- Received November 6, 2017
- Accepted November 28, 2017
- Published online April 16, 2018.
- Jaffar M. Khan, BM, BCha,
- Robert J. Lederman, MDa,
- Saurabh Sanon, MDb,
- Bradley G. Leshnower, MDc,
- Altayyeb Yousef, MDc,
- Patrick Gleason, MDc,
- Stamatios Lerakis, MDc,
- Toby Rogers, PhD, BM, BCha,
- Adam B. Greenbaum, MDd and
- Vasilis C. Babaliaros, MDc,∗ ()
- aCardiovascular Branch, Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, Maryland
- bStructural Heart Transcatheter Therapies, Tenet Health Palm Beach Gardens Medical Center, Palm Beach Gardens, Florida
- cStructural Heart and Valve Center, Emory University Hospital, Atlanta, Georgia
- dCenter for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
- ↵∗Address for correspondence:
Dr. Vasilis Babaliaros, Emory University, Hospital F606, 1364 Clifton Road, Atlanta, Georgia 30322.
A 78-year-old woman was referred with refractory heart failure. She had previous surgical mitral valve repair with a 32 Carpentier-Edwards Physio ring (Edwards Lifesciences, Irvine, California) and a polypropylene Alfieri stitch.
Echocardiography demonstrated restricted mitral valve leaflets, 2 eccentric regurgitant jets, and pulmonary vein flow reversal (Figure 1). Two orifices were evident on echocardiography and computed tomography (Figure 2).
The heart team determined the patient unsuitable for repeat cardiac surgery or standalone transcatheter mitral valve replacement (TMVR) due to high expected risk of valve maldeployment, “watermelon seeding” malapposition, and underexpansion with severe paravalvular leak due to the Alfieri stitch. A decision was made to use LAMPOON-related techniques (1,2) to cut the Alfieri stitch immediately before transseptal TMVR (Figure 3).
The institutional ethics review board of Emory University Hospital approved this retrospective report.
Two 6-F guiding catheters were advanced from trans-femoral sheaths retrograde into the left atrium through the separate mitral valve orifices. An 0.014” guidewire was advanced from one catheter and snare-retrieved from the second to form a guidewire loop around the Alfieri stitch (Figure 4). The guidewire loop was electrified and tensioned, lacerating the anterior leaflet tip horizontally adjacent to the suture. The result was a single mitral orifice in which the transcatheter heart valve was deployed (Figure 5).
Blood pressure reduced transiently during retrograde catheter manipulation but not laceration, requiring intra-aortic balloon pump counterpulsation. Laceration was successful requiring 2 to 3 s of continuous duty cycle (“cutting”) radiofrequency energy at 70 W. The valve was well seated with a good hemodynamic result (Figure 6). The patient was discharged on day 9 with class I symptoms and no stroke.
Patients with previous Alfieri stitch or MitraClip (Abbott Vascular, Santa Clara, California) may be excluded from TMVR. We describe a technique to resect the anterior leaflet tip from the suture attachment, enabling TMVR.
The authors are grateful to Dr. Melissa Fusari for her clinical guidance.
The work was supported by the Division of Intramural Research, National Heart Lung and Blood Institute, National Institutes of Health Grant No. Z01-HL006040. Dr. Sanon has served as a proctor and consultant or speaker for Edwards Lifesciences, Abbott Vascular, St. Jude Medical, and Baylis Medical; and has equity interest in Edwards Lifesciences and in Boston Scientific. Dr. Leshnower is on the Speaker Bureau for Medtronic. Dr. Lerakis has served as a consultant for Abbott Vascular; and his employer has research contracts for multicenter investigation of transcatheter aortic and mitral devices from Edwards Lifesciences, Abbott Vascular, Medtronic, St. Jude Medical, and Boston Scientific. Dr. Greenbaum has served as a proctor for Edwards Lifesciences and St. Jude Medical. Dr. Babaliaros has served as a consultant and investigator for Edwards Lifesciences and for Abbott Vascular; and his employer has research contracts for multicenter investigation of transcatheter aortic and mitral devices from Edwards Lifesciences, Abbott Vascular, Medtronic, St. Jude Medical, and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 6, 2017.
- Accepted November 28, 2017.
- Khan J.M.,
- Rogers T.,
- Schenke W.H.,
- et al.
- Babaliaros V.C.,
- Greenbaum A.B.,
- Khan J.M.,
- et al.