Author + information
- Received September 22, 2017
- Revision received October 9, 2017
- Accepted October 24, 2017
- Published online April 16, 2018.
- aDivision of Interventional Cardiology, Heart Team, University Hospital, London Health Sciences Centre, Western University, London, Canada
- bDivision of Cardiac Surgery, St Paul’s Hospital, University of British Columbia, Vancouver, Canada
- cDivision of Cardiac Surgery, Heart Team, University Hospital, London Health Sciences Centre, Western University, London, Canada
- ↵∗Address for correspondence:
Dr. Rodrigo Bagur, Division of Cardiology, London Health Sciences Centre, Department of Medicine, Western University, 339 Windermere Road, University Hospital, N6A5A5, London, Ontario, Canada.
A 69-year-old man with a previous history of mitral valve repair plus aortic valve replacement subsequently developed prosthetic valve endocarditis and underwent aortomitral curtain reconstruction and mitral valve re-repair with a 38-mm Memo 3D (LivaNova, London, United Kingdom) ring and a Bentall procedure with a 29-mm bileaflet mechanical valve conduit (St. Jude Medical, St. Paul, Minneapolis). More recently, he developed recurrent severe mitral regurgitation and recurrent admissions due to congestive heart failure with reduced left ventricular ejection fraction of 35% to 40%. The mean transmitral pressure gradient was 6.5 mm Hg. Although his pre-operative risk score as assessed by the Society of Thoracic Surgeons score was 6%, based on 2 previous sternotomies, he was deemed most suitable for a transcatheter-based approach. The area of a 38-mm Memo 3D ring is measured at 6.34 cm2, and in addition, being a D-shape semirigid ring, the area may increase with a balloon-expandable transcatheter valve. Moreover, given the fact of the circular profile of the balloon-expandable valve, the risk of valve embolization and paravalvular leakage would be high. Hence, transcatheter mitral valve-in-ring (TMV-in-R) replacement was planned with a 35-mm TIARA TMV (Neovasc Inc., Richmond, Canada) that is suitable for an annular area between 6 and 10 cm2. Notably, due to concerns about impeding the proper functioning of the mechanical aortic valve, a pre-operative 3-dimensional-(3D)–printed model was constructed based on the computed tomography images. Hence, we simulated TMV-in-R replacement by positioning a TIARA valve within the mitral ring of the patient-specific 3D-printed phantom model to predict adequate clearance between the aortic leaflets and the proposed TIARA-TMV (Figure 1, Online Video 1). The procedure was performed in a hybrid operation room under fluoroscopy and 3D transesophageal echocardiography guidance. Successful TMV-in-R replacement was performed with excellent clinical and hemodynamic results. The mean transmitral pressure gradient at hospital discharge was 3.4 mm Hg and no mitral regurgitation was observed. The patient was discharged-home 7 days post TMV-in-R replacement.
A unique feature of the TIARA-TMV is that it does not require oversizing as the mode of fixation. The ventricular tabs anchor the valve onto the fibrous trigone and posterior shelf. In addition, it captures the anterior MV leaflet and eliminates the risk of systolic anterior motion.
The present case illustrates the complementary use of 3D-printed models to computed-tomography images for planning complex transcatheter structural heart valve interventions.
Dr. Cheung has served as a consultant to Neovasc Inc.; and as the principal investigator on TIARA Early Feasibility Trial. Dr. Chu has served on the Speakers Bureau for Medtronic, LivaNova, Symetis, and Abbott Vascular. Dr. Kiaii has served as a consultant for Medtronic, Boston Scientific, Johnson & Johnson, and LivaNova; speaker for Medtronic, Boston Scientific, and Johnson & Johnson; and proctor for Medtronic, Boston Scientific, and LivaNova. Dr. Bagur has reported that he has no relationships relevant to the contents of this paper to disclose.
- Received September 22, 2017.
- Revision received October 9, 2017.
- Accepted October 24, 2017.
- 2018 American College of Cardiology Foundation