Author + information
- Received December 5, 2016
- Accepted December 15, 2016
- Published online February 15, 2017.
- David E. Kandzari, MD∗ (, )
- Harold Carlson, MD,
- John P. Gott, MD,
- Prashant Kaul, MD and
- W. Morris Brown, MD
- ↵∗Address for correspondence:
Dr. David E. Kandzari, Suite 2065, Piedmont Heart Institute, 95 Collier Road, Atlanta, Georgia 30309.
A 46-year-old woman with a history of Marfan Syndrome experienced witnessed cardiac arrest with persistent shock requiring circulatory support with extracorporeal membrane oxygenation (ECMO). In 2000, the patient underwent ascending aortic root replacement and mechanical bileaflet valve replacement followed by repeat sternotomy in 2012 with bypass grafting to the left anterior descending artery and left main artery patch closure for progressive coronary aneurysmal enlargement.
Coronary angiography demonstrated no significant right coronary artery disease but severe stenosis at the origin of the single venous bypass graft to the left coronary anatomy (Figure 1). During successful percutaneous revascularization of the bypass graft, a fixed, immobile leaflet of the mechanical valve was identified (Figures 2A and 2B, Online Video 1). The international normalized ratio was within therapeutic range upon admission. Following surgical consultation, the risk of a third operation was considered prohibitive. Further, given prolonged cardiopulmonary resuscitation and ECMO cannulation, fibrinolytic therapy for possible valve thrombosis represented at least a relative contraindication.
With no alternative therapeutic options, we hypothesized that balloon expansion between the leaflet struts may free the fixed leaflet and restore mobility. The method was initially tested with a valve model in the catheterization laboratory. A coronary guidewire was then passed across the valve between the struts followed by advancement of a 2.5 × 20-mm angioplasty catheter (Figure 3A, Online Video 2). Inflation of the balloon immediately resulted in recovery of leaflet mobility (Figure 3B) with functional aortic regurgitation and no clinical or radiographic evidence of an embolic event (Figures 4A and 4B, Online Video 3).
Treatment options for prosthetic valve dysfunction are limited to surgery or fibrinolytic therapy, both of which were unfavorable in this situation. Following review of the medical literature, this case represents the first description of balloon “valvuloplasty” for mechanical valve dysfunction.
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.
- Received December 5, 2016.
- Accepted December 15, 2016.
- American College of Cardiology Foundation