Author + information
- Received November 13, 2015
- Accepted November 19, 2015
- Published online March 14, 2016.
- Alan F. Vainrib, MDa,
- Michael J. Moses, BAa,
- Ricardo J. Benenstein, MDa,
- Alex Reyentovich, MDa,
- Mathew R. Williams, MDa,b,
- James N. Slater, MDa and
- Muhamed Saric, MD, PhDa,∗ ()
- aLeon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York
- bDivision of Cardiac Surgery, New York University Langone Medical Center, New York, New York
- ↵∗Reprint requests and correspondence:
Dr. Muhamed Saric, Echocardiography Lab, Noninvasive Cardiology, New York University, 560 First Avenue, New York, New York 10016.
- 3D transesophageal echocardiography
- mitral valve
- percutaneous balloon valvuloplasty
- prosthetic valve stenosis
A 77-year-old woman with a history of failed mitral valve (MV) repair with severe symptomatic mitral regurgitation underwent MV replacement with a 25-mm Carpentier-Edwards PERIMOUNT Magna bovine bioprosthesis (Edwards Lifesciences, Irvine, California) with resolution of symptoms.
After 6 months, she developed progressive dyspnea on exertion. A 2-dimensional (2D) and 3-dimensional (3D) transesophageal echocardiogram (TEE) demonstrated severe prosthetic MV stenosis due to commissural fusion (MV area by 3D TEE planimetry 0.6 cm2) and no mitral regurgitation (Figures 1A and 1B; Online Video 1A).
Given the expected high morbidity and mortality of a third valve surgery, she underwent percutaneous balloon valvuloplasty (PBV) of her mitral bioprosthesis under fluoroscopic and TEE guidance, as catheter-based valve-in-valve (ViV) replacement was not yet available. After 2 inflations of a 26-mm Inoue balloon system (Toray, Tokyo, Japan) (Figures 1C and 1D, Online Videos 1C and 1D), the mean diastolic MV pressure gradient decreased from 16 to 6 mm Hg at a heart rate of 60 beats/min with wider commissural separation of prosthetic leaflets. MV area increased from 0.6 to 1.5 cm2 with no mitral regurgitation (Figures 1E and 1F, Online Video 1E).
Two years later, she redeveloped severe exertional dyspnea. 2D and 3D TEE demonstrated recurrent bioprosthetic mitral stenosis with commissural fusion (Figures 2A and 2B, Online Video 2AB). She then underwent a successful ViV procedure using a 26-mm Sapien XT transcatheter valve (Edwards Lifesciences) via transapical approach (Figures 2C to 2F, Online Videos 2C, 2D, and 2EF) with resolution of symptoms.
Although PBV is the treatment of choice for native MV stenosis due to commissural fusion, reports of valvuloplasty for bioprosthetic MV stenosis are rare and there is equipoise toward its efficacy and safety (1–3). Ours appears to be the first reported case performed using both 3D TEE guidance and fluoroscopy. This case demonstrates the utility of PBV for prosthetic stenosis due to leaflet fusion, perhaps as an option for temporary palliation of symptoms in patients with a high surgical risk or those awaiting a more definitive treatment such as transcatheter ViV implantation (4).
For supplemental videos, please see the online version of this article.
Dr. Williams is a consultant for and has received research funding from Medtronic, Inc. Dr. Saric is a member of the Speakers Bureau for Philips and Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received November 13, 2015.
- Accepted November 19, 2015.
- American College of Cardiology Foundation