Author + information
- Received March 3, 2011
- Revision received May 25, 2011
- Accepted June 2, 2011
- Published online November 1, 2011.
- Matteo Montorfano, MD⁎,
- Azeem Latib, MD⁎,†,
- Alaide Chieffo, MD⁎,
- Shahram Moshiri, MD‡,
- Annalisa Franco, MD§,
- Antonio Grimaldi, MD∥,
- Ottavio Alfieri, MD∥ and
- Antonio Colombo, MD⁎,†,⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Antonio Colombo, EMO-GVM Centro Cuore Columbus, Via Buonarroti 48, 20145 Milan, Italy
Transcatheter heart valve (THV) implantation with the valve-in-valve technique is a low-risk treatment option for patients with failing bioprosthetic valves (1).
A 71-year-old man with rheumatic mitral stenosis underwent mitral valve replacement 12 years ago with a 27-mm Carpentier-Edwards bioprosthesis (Edwards Lifesciences, Inc., Irvine, California). He presented with biventricular failure due to severe prosthetic mitral stenosis (valve area 0.8 cm2, mean gradient 19 mm Hg), despite palliative valvuloplasty. Surgical risk was deemed unacceptably high (Logistic EuroScore = 44.8%; Society of Thoracic Surgeons predicted risk of mortality = 5.3%). Thus, he underwent transcatheter mitral valve-in-valve implantation by the transvenous-transeptal-anterograde approach, performed under local anesthesia and conscious sedation. After transseptal puncture, a Swan-Ganz catheter was manipulated across the mitral prosthesis and aortic valve into the ascending aorta. A 260-cm, 0.035-inch Amplatz Extra Stiff guidewire (Cook, Inc., Bloomington, Indiana) was advanced into the descending aorta and snared with a 25-mm gooseneck, creating a venous–arterial circuit (Fig. 1A). The gooseneck was left attached to the Amplatz wire to allow sufficient length of the wire system (Fig. 1B). A 24-F Edwards sheath was placed in the right femoral vein, and the atrial septum was dilated with a 10 × 40 mm balloon. A 26-mm Sapien XT valve (Edwards Lifesciences) premounted on the Novaflex system could not cross the septum; the THV was retrieved, and further sepal dilation with a larger balloon was performed (Fig. 1C). The THV was re-advanced, and despite several attempts, coaxial positioning within the bioprosthesis was impossible (Fig. 2A). During rapid ventricular pacing to minimize movement, slow and gradual balloon inflation resulted in the valve becoming coaxial with an excellent final position (Figs. 2B and 2C). Transesophageal echocardiography demonstrated a well-functioning Sapien XT valve (Edwards Lifesciences), minimal mitral gradient (3 mm Hg), and moderate inter-valvular mitral regurgitation (i.e., between the bioprosthesis and Sapien XT). The patient tolerated the procedure well and was discharged 5 days later with marked symptomatic improvement. At 1-month follow-up, he was asymptomatic with no mitral regurgitation.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 3, 2011.
- Revision received May 25, 2011.
- Accepted June 2, 2011.
- American College of Cardiology Foundation