Author + information
- Received March 28, 2018
- Revision received April 10, 2018
- Accepted April 24, 2018
- Published online June 13, 2018.
- Dabit Arzamendi, MD, PhDa,∗ (, )
- Valeriano Ruiz, MDb,
- Raúl Ramallal, MDb,
- Maria Soledad Alcasena, MDb,
- Maria Teresa Beunza, MDc and
- Mariano Larman, MDd
- aDivision of Interventional Cardiology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
- bDivision of Interventional Cardiology, Complejo Hospitalario de Navarra, Pamplona, Spain
- cDivision of Imaging in Cardiology, Complejo Hospitalario de Navarra, Pamplona, Spain
- dDivision of Interventional Cardiology, Hospital de Donostia, San Sebastián, Spain
- ↵∗Address for correspondence:
Dr. Dabit Arzamendi, Division of Interventional Cardiology, Hospital de la Santa Creu i Sant Pau, Sant Antoni M. Claret, 167, 08025, Barcelona, Spain.
A 71-year-old woman with a history of rheumatic heart valve disease and prior aortic and mitral mechanical valve replacement (Carbomedics #21 and #29, CarboMedics Inc., Austin, Texas, respectively), was referred for transcatheter closure of a mitral perivalvular leak due to New York Heart Association functional class III heart failure.
Transesophageal echocardiogram revealed an 18 mm × 6 mm mitral paravalvular leak at 9 o’clock (surgeon view). Because of severe calcification of the mitral ring with a transseptal approach, only the wire, but not the sheath, could be crossed through the leak. Therefore, an arteriovenous loop through the aortic valve was used to gain support, which enabled us to successfully advance the sheath through the mitral leak. At this point, the patient went into cardiogenic shock. A severe aortic regurgitation was confirmed by the aortogram, due to dislodgement of 1 of the aortic mechanical valve leaflets, which had embolized to the abdominal aorta (Figures 1A and 1B, Online Video 1⇓). The decision was made to implant a transcatheter aortic valve in a desperate maneuver to recover the patient (Figure 1C). The valve was implanted uneventfully, and echocardiography subsequently confirmed no residual aortic regurgitation (Figure 1D). Mitral leak was successfully closed with an AVP III (Abbott Vascular [formerly St. Jude Medical], St Paul, Minnesota) 12 mm × 5 mm device in the same procedure.
Leaflet dislodgments are rare complications of mechanical valves. They are mostly related to invasive interventions (cardiac catheterization, atrial fibrillation ablation) (1), but spontaneous dislodgements have also been reported (2). Mortality is high because most patients develop acute cardiogenic shock, and urgent surgery is warranted if feasible. However, most patients have a prohibitive surgical risk, given that they are in unstable hemodynamic condition and have already had a prior open-heart surgery. Transcatheter aortic valve replacement with an S3 valve (Edwards Lifesciences, Inc., Irvine, California) in mechanical aortic valve after leaflet embolization is feasible and can be considered in acute valve failure.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 28, 2018.
- Revision received April 10, 2018.
- Accepted April 24, 2018.
- 2018 American College of Cardiology Foundation