Author + information
- Mayra Guerrero, MD∗ (, )
- Dee Dee Wang, MD and
- William O’Neill, MD
- ↵∗Evanston Hospital / NorthShore University Health System, University of Chicago Pritzker School of Medicine, 2650 Ridge Avenue, Walgreen Building, 3rd Floor, Evanston, Illinois 60201
Transcatheter mitral valve replacement (TMVR) with the compassionate use of aortic transcatheter valves (THV) has emerged as an alternative to surgery in patients with severe MV disease with severe mitral annular calcification (MAC) who are not eligible for standard MV surgery due to high surgical risk. Although this may be a feasible alternative for inoperable patients, data from the TMVR in MAC Global Registry found that it is associated with important complications including valve embolization (1). Surgical rescue of an embolized valve carries an extremely high surgical risk in this patient population. We report a new method for percutaneous rescue of an embolized valve that may prevent the need for surgical rescue when a THV embolizes after TMVR.
A 59-year-old woman with symptomatic severe mitral stenosis and severe MAC was considered not a candidate for standard surgical MVR due to multiple comorbidities including severe chronic obstructive pulmonary disease, morbid obesity, systemic lupus erythematosus, and renal failure. She was referred to us for evaluation for TMVR. She had dyspnea on exertion, New York Heart Association functional class III for 6 months, and was hospitalized with class IV symptoms. Her left ventricular function was normal, and the MV area was 1.34 cm2 with a mean mitral gradient of 10.3 mm Hg. The mitral annular area measured by cardiac computed tomography (CT) was thought to be between 526 and 556 mm3. The heart team decided to offer her a transseptal TMVR with the compassionate use of a SAPIEN XT valve (Edwards Lifesciences, Irvine, California). A 26-mm size was chosen due to higher risk of left ventricular outflow tract obstruction predicted with a 29-mm SAPIEN XT valve based on cardiac CT analysis. She underwent transseptal TMVR with a 26-mm SAPIEN XT valve. The valve embolized to the left atrium immediately after deployment, most likely due to undersized valve chosen. The cardiac surgeon involved in her evaluation declined to offer surgical rescue due to her extremely high surgical risk. The balloon delivery system was removed, keeping the guidewire in place. An Amplatzer delivery sheath (St. Jude Medical, St. Paul, Minnesota) was introduced across the SAPIEN valve over the guidewire and a 30-mm Amplatzer septal occluder device (St. Jude Medical) was deployed with the left atrial disk at the distal edge of the THV stent, then was retracted and positioned against the intra-atrial septum at the site of septostomy performed for transseptal TMVR. The right atrial disc was deployed at the proximal edge of the THV stent on the right atrial side, keeping the SAPIEN XT valve secured across the intra-atrial septum. Further attempts of TMVR were not performed. A follow-up CT scan showed the SAPIEN XT valve and Amplatzer septal occluder device in stable position across the intra-atrial septum (Figure 1). The patient remained stable from cardiac standpoint with less severe mitral stenosis after valvuloplasty effect of the TMVR attempt. However, she died of multiorgan failure 3 weeks later. Valve embolization, although infrequent, is one of the known complications of TMVR. The percutaneous rescue technique we present herein may be an option for patients who are not candidates for surgical rescue of an embolized valve.
Please note: Dr. Guerrero has served as a proctor for and has received research grant support from Edwards Lifesciences. Dr. O'Neill has served as a proctor for and consultant to Edwards Lifesciences. Dr. Wang has reported that she has no relationships relevant to the contents of this paper to disclose.
- 2017 American College of Cardiology Foundation