Author + information
- Received July 25, 2016
- Accepted August 11, 2016
- Published online November 14, 2016.
- Ben Ren, MD, PhDa,
- Zouhair Rahhab, MDa,
- Jan von der Thüsen, MDb,
- Joost Daemen, MD, PhDa,
- Marcel L. Geleijnse, MD, PhDa,
- Peter P.T. de Jaegere, MD, PhDa,
- Arie Pieter Kappetein, MD, PhDc and
- Nicolas M. Van Mieghem, MD, PhDa,∗ ()
- aDepartment of Cardiology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
- bDepartment of Pathology, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
- cDepartment of Cardiothoracic Surgery, Thoraxcenter, Erasmus University Medical Center, Rotterdam, the Netherlands
- ↵∗Reprint requests and correspondence:
Dr. Nicolas M. Van Mieghem, Department of Interventional Cardiology, Thoraxcenter, Erasmus MC, Office Building 171, ’s Gravendijkwal 230, Rotterdam 3015 CE, the Netherlands.
A 75-year-old woman with degenerative mitral stenosis and a prior aortic bioprosthesis was referred for potential valvular intervention. She had been symptomatic (New York Heart Association functional classes III to IV), with a history of syncope, chronic obstructive pulmonary disease, latent tuberculosis, and thrombocytopenia. She was considered inoperable because of excessive comorbidities (Society of Thoracic Surgeons score 9.5%) by the heart team consensus. Transthoracic echocardiography revealed a severely calcified mitral annulus with a transvalvular mean pressure gradient of 13 mm Hg. Transesophageal echocardiography confirmed a heavily calcified mitral apparatus, including the chordae tendineae, with an immobile posterior leaflet (Figure 1A, Online Video 1). The mitral orifice area was 0.9 cm2 by 3-dimensional planimetry. The Wilkins score was 10, ruling out safe percutaneous balloon mitral valvuloplasty (1). Extensively calcified mitral annulus and leaflets were also seen on multislice computed tomography. The mitral annular area was 526 mm2, and the perimeter was 84 mm, with a minimum diameter of 22 mm and a maximal diameter of 31 mm (Figure 1B). On the basis of the findings of multislice computed tomography, an in vitro valve implantation was conducted in a reconstructed 3-dimensional printed model (Figure 1C, Online Videos 2 and 3), which confirmed the suitability of transapical transcatheter mitral valve implantation with a 27-mm Lotus valve (Boston Scientific, Natick, Massachusetts). The procedure was performed under general anesthesia, supported with fluoroscopy and transesophageal echocardiography. A cerebral embolic protection device was deployed in the brachiocephalic trunk and left common carotid artery prior to the valve implantation to collect potential debris released during the procedure (Figure 1D). A coronary guidewire in the left circumflex coronary artery served as a fluoroscopic landmark for Lotus valve positioning (Figure 1E). Through a left lateral minithoracotomy, the Lotus valve was smoothly delivered into the mitral annulus and gradually deployed (Online Video 4). After 1 position adjustment, the valve was released somewhat higher above the mitral annulus (Figure 1F) to avoid interference with the left ventricular outflow tract and aortic bioprosthesis. The transvalvular mean pressure gradient was 2 mm Hg, with mild paravalvular leakage (Figure 1G). Debris was captured in the embolic protection device (Figure 1H) and consisted of platelet aggregates, endothelium, fragments of connective tissue, myxoid stroma, and myocardium (Figure 1I).
As previously reported, transcatheter mitral valve implantation in a native calcified mitral valve and degenerated bioprosthesis is feasible with balloon-expandable valves (2,3). In our case, considering the sizing and repositionable and retrievable characteristics of the prosthesis, the mechanically expanded Lotus valve was chosen, also avoiding the fast pacing required in balloon-expandable valve implantation. Considering the severity of mitral apparatus calcification, an embolic protection device was implanted to prevent potential cerebral complications. The implantation process evolved smoothly, with a satisfactory result, showing that the Lotus valve is feasible for this procedure.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Ren and Rahhab contributed equally to this work.
- Received July 25, 2016.
- Accepted August 11, 2016.
- American College of Cardiology Foundation
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