Author + information
- Received November 5, 2014
- Revision received December 22, 2014
- Accepted January 15, 2015
- Published online June 1, 2015.
- Omar Abdul-Jawad Altisent, MD,
- Eric Dumont, MD,
- François Dagenais, MD,
- Mario Sénéchal, MD,
- Mathieu Bernier, MD,
- Kim O’Connor, MD,
- Jean-Michel Paradis, MD,
- Sylvie Bilodeau, MD,
- Sergio Pasian, MD and
- Josep Rodés-Cabau, MD∗ ()
- ↵∗Reprint requests and correspondence:
Dr. Josep Rodés-Cabau, Quebec Heart & Lung Institute, 2725 Chemin Ste-Foy, Quebec City, Quebec, Canada.
A 66-year old man with severe functional mitral regurgitation (Figure 1A) secondary to chronic ischemic cardiomyopathy (previous myocardial infarction and coronary artery bypass grafting) and advanced heart failure (left ventricular ejection fraction: 25%; New York Heart Association [NYHA] functional class III) was considered to be at very high surgical risk and was finally accepted by the Heart Team for transcatheter mitral valve implantation (TMVI) with the FORTIS transcatheter valve (Edwards Lifesciences, Irvine, California) (Figures 1B and 1C).
The procedure was performed using previously described techniques (1). In brief, the valve was inserted in the left ventricular cavity using a 40-French delivery catheter through the left ventricular apex. The valve prosthesis paddles were unsheathed to capture the native mitral leaflets at the A2-P2 level (Online Video 1). After confirmation of native mitral leaflet capture, full deployment of the valve system was successfully performed (Figure 1D, Online Video 2).
After valve deployment, transesophageal echocardiography (TEE) images revealed the presence of a mild to moderate perivalvular leak at the level of the posteromedial commissure (Figure 1E, Online Video 3; Figure 1F, Online Video 4). However, cardiac magnetic resonance (CMR) showed the absence of any residual leak (Figure 1G, Online Video 5), and multislice computed tomography demonstrated the correct positioning and atrial anchoring of the valve system (Figures 1H and 1I, Online Video 6). The post-procedural period was uneventful, and the patient was discharged 5 days after the intervention. At 1-month follow-up, the patient was in NYHA functional class I, and TEE showed a minimal “pseudo leak” (Online Video 7) and a mean transvalvular gradient of 3 mm Hg.
TMVI has recently emerged as a new option for the treatment of mitral regurgitation. An accurate evaluation of the presence of residual leaks remains of maximal importance for determining device performance and success. This report shows that the interpretation of residual leaks after TMVI may be challenging. We hypothesize that the relationship between the captured leaflets (A2-P2) and the free leaflets (A3-P3) generated an eccentric turbulent flow between the native leaflets and the valve prosthesis that resulted in an image suggestive of paravalvular leak. However, the eccentric jet did not extend into the atrium (“pseudo leak”), as further confirmed by CMR, and tended to disappear over time, probably due to new tissue growth covering the paddles of the valve prosthesis.
For accompanying videos, please see the online version of this article.
Dr. Rodés-Cabau is consultant for and has received research grant from Edwards Lifesciences. Dr. Dumont is consultant for Edwards Lifesciences. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 5, 2014.
- Revision received December 22, 2014.
- Accepted January 15, 2015.
- American College of Cardiology Foundation