Transcatheter valve-in-valve implantation for degenerated mitral valve bioprosthesis under 3D echocardiographic guidance

Abstract

Transcatheter mitral valve-in-valve replacement is increasingly being performed as operator and center experience in transcatheter valve replacement technology and techniques have accrued. Complications, such as valve embolization and paravalvular regurgitation, still occur and relate to valve deployment. The use of novel imaging techniques, such as 3D echocardiography, allows for better differentiation of cardiac structures and appropriate positioning of the transcatheter valve using well-visualized anatomical landmarks. Here the authors describe in images and video the use of 3D echocardiography for deployment of a mitral valve-in-valve.

Keywords::

• 3D echocardiography
• mitral valve
• transcatheter

In an aging population, an increasing number of patients with a history of mitral valve replacement are requiring redo surgery. Mortality for patients older than 75 years old who undergo repeat surgery is prohibitive, with a 3-year mortality close to 40% [1]. Transcatheter valve replacement techniques are now established as standard of care for high-risk elderly patients with severe aortic stenosis; however, there is limited data on the use of the technology for mitral valve-in-valve replacement (MVIV). Here we present the case of a high-risk patient with severe mitral regurgitation due to degenerated anterior leaflet of a bioprosthetic valve, who underwent successful MVIV under 3D echocardiographic guidance alone.

Case

An 86 year-old male with valvular heart disease and a history of both aortic and mitral valve replacement surgery in the distant past presented with worsening exertional dyspnea, now occurring on minimal activity. Echocardiogram on admission revealed an anterior flail leaflet of the 29 mm Mosaic bioprosthetic valve (Medtronic, Minneapolis, MN, USA) in the mitral position and severe mitral regurgitation with a posteriorly directed jet. Left ventricle was hyperdynamic and normal in size, while the left atrium was severely dilated and estimated right ventricular systolic pressure elevated. Cardiothoracic surgery was consulted for intervention; however, the patient was deemed inoperable given his age, prior sternotomy and significant coronary artery disease with high-grade stenoses in both the right coronary and posterior descending arteries. The decision was taken to proceed with echo-guided transapical transcatheter MVIV replacement.

After intubation, transesophageal echo probe was inserted to visualize the degenerated 29 mm Mosaic bioprosthetic valve and to guide the deployment of a 26 mm Edwards SAPIEN valve (Edwards Lifesciences, Irvine, CA, USA). Mid-esophageal view of the mitral valve revealed a degenerated bioprosthesis with severe regurgitation and a posteriorly directed jet, evident on Supplementary Videos 1A & 1B. A micropuncture wire followed by a delivery sheath was advanced through the left ventricular apex up to the mitral position. The delivery catheter was visualized in real-time using 3D transesophageal echo in order to identify the appropriate position for valve-in-valve deployment (Supplementary Video 2). It is noteworthy that 3D transesophageal echo has the ability to differentiate the frame of the valve from the balloon that the valve is mounted on (Supplementary Video 2). Appropriate positioning using these markers is essential to prevent valve embolization and paravalvular regurgitation post-deployment [2]. Once positioned adequately, the valve-in-valve was deployed successfully under rapid ventricular pacing (Supplementary Video 3). Repeat imaging post-deployment showed appropriately seated MVIV (Supplementary Video 4), with absence of regurgitation on 2D Doppler echo (Supplementary Video 5).

The patient did well post-operatively. The remainder of his hospitalization was uneventful, and he was discharged on post-operative day 7. This case illustrates the usefulness of 3D echocardiography in the successful guidance and positioning of bioprosthetic valves delivered using transcatheter technology.

Financial & competing interests disclosure

Lerakis S, Thourani and Babaliaros also received consulting fees honoraria from Edwards Lifesciences. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.