Emergency transapical mitral valve-in-valve implantation for bioprosthesis failure: transapical implantation of an Edwards Sapien-XT in a dysfunctional mitral bioprosthesis in a critical patient
Valve-in-Valve (VIV) Transcatheter Aortic Valve Replacement (TAVR) is now the treatment of choice in high-surgical-risk patients with failing aortic bioprosthesis. Although less performed, VIV-Transcatheter Mitral Valve Replacement (TMVR) is a valid treatment option for selected high-risk patients with degenerated mitral bioprostheses. Several cases of elective ViV- TAVR and -TMVR have been reported but only few were performed in critical hemodynamic conditions.
We report the case of a patient underwent balloon-expandable transapical mitral valve-in-valve implantation in an emergency setting due to a severe stenosis of a bioprosthesis in mitral position. The procedure was successfully performed, with no residual mitral regurgitation or paravalvular leaks, and uneventful.
Transcatheter transapical mitral valve-in-valve implantation could represent a feasible and effective strategy even in critical setting.
KeywordsMitral valve stenosis Bioprosthesis Transcatheter valve implantation Valve-in-valve Transapical Mitral bioprosthesis Emergency
- AV block
Chronic Obstructive Pulmonary Disease
Continuous Veno-Venous Hemofiltration
- ECG-gated MDCT
Electrocardiographic-gated Multiple Detector Computed Tomography
New York Heart Association
Transcatheter Aortic Valve Replacement
Valve-in-valve Transcatheter Mitral Valve Replacement
Valve-in-Valve (VIV) Transcatheter Aortic Valve Replacement (TAVR) is now the treatment of choice in high-surgical-risk patients with failing aortic bioprosthesis . Although less performed, VIV-Transcatheter Mitral Valve Replacement (TMVR)  represents a valid treatment option for selected high-risk patients with degenerated mitral bioprostheses. Several cases of elective ViV- TAVR and -TMVR have been reported, but only a few were performed in critical hemodynamic conditions, especially for dysfunctioning mitral bioprosthesis [3, 4, 5]. Over the last decade, the use of bioprosthesis or mitral valve reconstruction, instead of mechanical valves, has shown an important worldwide increase thanks to the improved long-term results and inspired to the desire of avoiding the need of life-long systemic anticoagulation. The durability of bioprostheses, especially in mitral position, can be very variable, depending on patient’s and valve characteristics. Although surgical redo operation is often possible, when there are no specific contraindications, it’s widely known that is accompanied by an increased mortality depending on age, comorbidities and elective or urgent status of the procedure. In this scenario, the incidence of failing surgical valves in high surgical risk patients will surely increase. Even more important is the choice of the right treatment option in patients with critical conditions with high or unacceptable surgical risks. Usually stented bioprosthesis present a progressive deterioration, evaluable with a correct echocardiographic follow-up, permitting a comfortable planning of the procedure but sometimes patients could be admitted directly to the ER in life-threating conditions without previous important symptoms. We report the case of a patient underwent balloon-expandable transapical mitral valve-in-valve implantation in an emergency setting due to a severe mitral stenosis of a surgical bioprosthesis.
Preoperative TransThoracic Echocardiography. (MP4 4.90 mb)
Postoperative TransThoracic Echocardiography. (MP4 5.45 mb)
Postoperative TransThoracic Echocardiography. (MP4 2.30 mb)
Discussion and conclusions
Degeneration of surgically implanted bioprosthesis in elderly patients is an increasing problem due to the longer life-expectancy. Moreover, this issue is going to interest also a younger population due to the growing percentage of bioprosthesis implantation instead of the mechanical ones. According to the current literature, the perioperative risk of redo surgical intervention may reach high percentage, up to 15% for redo aortic replacement, depending on age, clinical conditions and comorbidities. To this increasing number of patients, we should add the several situations in which surgery can’t be performed because of technical contraindications (porcelain aorta, really calcified mitral annulus, multiple redos, frailty, etc.). We are in an era where TAVR is already the therapy of choice for high-risk patients, and in the next year, its indications are moving to the moderate-risk ones. The valve-in-valve concept was developed by Walther et al. in 2007 with the intent of decrease the reoperative risk in patients with a dysfunctional bioprosthesis. ViV-TAVR is nowadays a standard procedure to treat elderly patients with degenerated bioprosthesis, while mitral valve-in-valve implantation is not yet so frequent probably due to the difficulties of reaching the mitral with a peripheral approach. The need of a transapical puncture, as a unique option, is probably going to end with the expanding possibilities linked to transeptal system development. Technically, the deployment of a transcatheter valve into a surgically implanted bioprosthesis is a quite simple procedure for skilled operators thanks to the possibility to use the annulus of the surgical prosthesis as a reference point for the deployment of the new one. Furthermore, using the degenerated valve as a landing zone for the implantation assure a good stability of the transcatheter prosthesis and it’s usually not accompanied by significant paravalvular leaks. Transapical approach requests high surgical skills, but with the actual low-profile introducer sheaths the risk of complications is minimized.
According to our experience, transapical valve-in-valve transcatheter mitral implantation can be a feasible and safe way to treat bioprosthesis dysfunction even in urgent and emergency settings, as we have shown in this case.
All the staff of Centro Cardiologico Monzino.
Availability of data and materials
Available with specific request.
First and last authors equally collaborate to the work. Data finding and collecting: MZ, SM, GB, FA, RB. Data analisis: MS, MZ. Paper writing: MS, MZ, MR. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The work has been performed under the extensive approbation of IRCCS Centro Cardiologico Monzino Institutional Review Board and it conforms to the ethical guidelines of the Declaration of Helsinki.
Consent for publication
Signed by the patients at admission.
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