Author + information
- Received July 3, 2012
- Accepted July 19, 2012
- Published online January 1, 2013.
- Jean-Michel Paradis, MD,
- Susheel K. Kodali, MD,
- Rebecca T. Hahn, MD,
- Isaac George, MD,
- Benoit Daneault, MD,
- Elana Koss, MD,
- Tamim M. Nazif, MD,
- Martin B. Leon, MD and
- Mathew R. Williams, MD⁎ ()
- ↵⁎Reprint requests and correspondence:
Dr. Mathew R. Williams, Columbia University Medical Center, NewYork-Presbyterian Hospital, New York, New York 10032
An 85-year-old man was recently admitted to our institution with congestive heart failure (New York Heart Association functional class III/IV) and hemolytic anemia. The patient had a prior history of Streptococcus viridans bacterial endocarditis that resulted in severe aortic and mitral regurgitations. In 2002, he underwent surgical aortic (Carpentier-Edwards #25, Edwards Lifesciences, Irvine, California) and mitral (Hancock modified #29, Medtronic, Minneapolis, Minnesota) valve replacements. Transesophageal echocardiogram (TEE) performed during the recent hospitalization showed that the left ventricular ejection fraction was 55%. The Hancock modified bioprosthesis in the mitral position was well seated, but there was severe mitral regurgitation caused by a flail leaflet (Fig. 1A,Online Video 1). The mitral bioprosthesis was oval-shaped, and the internal diameters were measured to be 21 × 23.8 mm (Fig. 1B). In addition, there was severe stenosis of the Carpentier-Edwards valve in the aortic position with an aortic valve area (AVA) of only 0.9 cm2. On 3-dimensional TEE, the internal diameter of the valve was measured to be 24 mm (Fig. 2).
On the basis of his clinical presentation and the TEE findings, the patient was felt to require reoperative aortic and mitral valve replacements. He was evaluated by 2 cardiothoracic surgeons and judged to be inoperable on the basis of his advanced age, frailty, multiple comorbidities, and the complexity of the proposed surgery. Therefore, it was decided to proceed with transapical, transcatheter, double valve-in-valve implantation using 2 commercially available RetroFlex 3 transfemoral devices (Edwards Lifesciences, Irvine, California). In the hybrid operating room, without pre-dilation but under rapid ventricular pacing, a 26-mm Edwards SAPIEN transcatheter heart valve (THV) was first deployed within the Carpentier-Edwards valve in the aortic position (Online Video 2). With a 2-step inflation technique, an Edwards SAPIEN 26-mm THV was then deployed within the Hancock modified bioprosthesis in the mitral position (Online Video 3). TEE after deployment of both valves showed excellent function of the new aortic prosthetic valve with an AVA of 2.08 cm2, peak and mean gradients of 12 and 6 mm Hg, respectively, and no significant aortic insufficiency. Moreover, there was only trace residual mitral regurgitation, and no significant stenosis (mitral valve area 1.65 cm2).
For supplementary videos and their legends, please see the online version of this paper.
Drs. Paradis, Kodali, Daneault, and Williams have received consulting fees from Edwards Lifesciences. Dr. Kodali is also a consultant for St. Jude Medical; he serves on the Scientific Advisory Board and has equity in Thubrikar Aortic Valve Inc. Dr. Hahn is a consultant for Abbott Vascular and the COAPT trial. Dr. Leon is a nonpaid member of the Scientific Advisory Board of Edwards Lifesciences and Medtronic Vascular; he is on the Executive Committee of the PARTNER trial. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 3, 2012.
- Accepted July 19, 2012.
- American College of Cardiology Foundation