Author + information
- Received October 5, 2015
- Accepted October 22, 2015
- Published online February 22, 2016.
- Lennart van Gils, MDa,
- Ramón Rodriguez Olivares, MDa,
- Ben Ren, MD, PhDa,
- Marcel L. Geleijnse, MD, PhDa,
- Arie-Pieter Kappetein, MD, PhDb,
- Peter P.T. De Jaegere, MD, PhDa and
- Nicolas M. Van Mieghem, MD, PhDa,∗ ()
- aDepartment of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
- bDepartment of Thoracic Surgery, Thoraxcenter, Erasmus Medical Center, Rotterdam, the Netherlands
- ↵∗Reprint requests and correspondence:
Dr. Nicolas M. Van Mieghem, Department of Interventional Cardiology, Thoraxcenter, Erasmus MC, Room Bd 171, ‘s Gravendijkwal 230, 3015 CE Rotterdam, the Netherlands.
A 73-year old man presented with acute cardiac decompensation due to severe degenerative mitral regurgitation (Figures 1A and 1B). The patient previously underwent surgical aortic valve replacement with a mechanical valve. The patient was declared inoperable by heart team consensus based on excessive comorbidities. After staged left main bifurcation rotablation and stenting (Figures 1C and 1D), the patient was accepted for transapical transcatheter mitral valve implantation (TMVI) with the CardiAQ transcatheter heart valve (Edwards Lifesciences, Irvine, California) (Figure 2A) under compassionate use. Pre-procedural imaging work-up confirmed eligibility for the procedure in terms of overall anatomy and sizing. Relative orientation of the aortic mechanical valve and its distance to the mitral annular plane were deemed reassuring (Figures 1E and 1F). The procedure was supported by fluoroscopic and transesophageal echocardiography guidance. Through a left lateral minithoracotomy, the CardiAQ valve was smoothly navigated over a stiff guidewire into the mitral annulus and gradually deployed (Online Video 1), with no residual mitral regurgitation on transesophageal echocardiography (Figure 2D). Final release was quickly followed by hemodynamic compromise due to massive aortic regurgitation (Figure 2E, Online Video 2) caused by 1 immobile leaflet of the aortic mechanical valve (Figure 2F, Online Video 3). Despite extracorporeal cardiopulmonary support and multiple bail-out transcatheter maneuvers, the patient succumbed to intractable cardiogenic shock. Autopsy revealed anatomically correct placement and sealing of the CardiAQ valve (Figure 2G). Despite excessive pre-procedural planning, 2 anchors of the CardiAQ valve eventually interfered with the aortic mechanical valve (Figures 2H and 2I). As previously described, the inherent radial force needed to anchor the stented valve might squeeze the left ventricular outflow tract (1,2). This case demonstrates that the left ventricular outflow tract is an essential yet dynamic anatomic structure for TMVI, especially in the case of an aortic mechanical valve. Proper understanding of the mitral valvular anatomy is crucial for the clinical implementation and further refinement of TMVI. We believe that the presence of an aortic mechanical valve currently is a formal contraindication for TMVI.
For supplemental videos and their legends, please see the online version of this article.
Prof. Dr. de Jaegere is proctor for Boston Scientific. Dr. Van Mieghem has received research grants from Boston Scientific, Medtronic, Claret Medical, and Edwards Lifesciences.
- Received October 5, 2015.
- Accepted October 22, 2015.
- 2016 American College of Cardiology Foundation
- Van Mieghem N.M.,
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