Transcatheter closure of a native mitral valve following mitral valve bypass surgery using a novel left atrial-to-left ventricle conduit-associated arteriovenous rail

Approximately 6–15% of patients with surgically implanted prosthetic valves can experience clinically significant prosthetic paravalvular regurgitation.¹

A 74-year-old female initially presented with New York Heart Association Class III dyspnoea and was found to have calcific mitral valve (MV) degeneration with severe mitral regurgitation (MR) and stenosis. The patient was evaluated by the heart team and felt to have a Society of Thoracic Surgery Risk Score of 1–2% for isolated MV surgery. Due to this low surgical risk, the patient was not considered a candidate for transcatheter MV replacement.² To avoid direct manipulation of the severe mitral annular calcification, the MV was surgically bypassed with a left atrial (LA)-to-left ventricle (LV) conduit (Figure 1A), which incorporated a 27 mm aortic Hancock 2 prosthesis within the conduit (see Supplementary material online, Figure S1).³ This technique of using an extracardiac conduit was originally developed to treat congenital cardiac defects, first described in 1982.⁴ To eliminate the severe native MR and complete the native MV bypass, an autologous pericardial patch was also sutured to the atrial aspect of the native MV orifice.

Figure 1.

(A–F) Pre- and post-interventional imaging. (A) Cardiac computed tomography 3D reconstruction shows an extracardiac course of the left atrial-to-left ventricle conduit. (B) 3D transoesophageal echocardiography demonstrates a left atrium surgeons’ view with arrows highlighting the dehisced portion of the mitral valve pericardial patch. (C) Doppler transoesophageal echocardiography shows the pre-procedural severity of mitral regurgitation across the surgically closed native mitral valve corresponding with the area of the dehisced patch. Additionally, an invasive haemodynamic tracing demonstrates severe mitral regurgitation. (D) Right anterior oblique/cranial view under fluoroscopy shows severe mitral annular calcification and the arteriovenous rail going through the native mitral valve and through an extracardiac route across the Hancock bioprosthesis lining the surgical left atrial-to-left ventricle conduit prior to snaring the wire in the right atrium. (E) Right anterior oblique/cranial view highlighting the first Amplatzer vascular occluder device being deployed across the native mitral valve using the rail for coaxial guidance. (F) 3D transoesophageal echocardiography intraprocedurally highlights (arrows) the two vascular occluder devices with associated improvement in the haemodynamic tracing of residual mitral regurgitation. Ao, aorta; AVP, Amplatzer vascular plug; ECG, electrocardiogram; LA, left atrium; LV, left ventricle; MAC, mitral annular calcification.

The patient returned 2 years after MV bypass surgery with recurrent symptoms. Echocardiography showed residual severe MR from partial pericardial patch dehiscence (Figure 1B and C). On multidisciplinary evaluation, the surgical risk was felt to be prohibitive as a result of the index procedure coupled with a redo sternotomy, and there was consensus for transcatheter closure of the dehisced pericardial patch covering the native MV orifice.

The femoral vein was accessed, and a transseptal puncture was made. A curled stiff wire was advanced from the LA through the native MV, dehisced patch, and into the LV. An initial arteriovenous rail was then created through snaring the femoral vein wire in the LV and being pulled anterograde through the aortic valve and externalized through the femoral artery. There was sub-optimal angulation for delivery of vascular occluder devices, so this rail system was revised. A novel rail system was decided upon for improved coaxial alignment, in which the femoral vein wire crossed the RA into the LA (transseptal puncture), through the native MV into the LV, retrograde through the LA-to-LV conduit back into the LA (through a second transseptal puncture), and across the septum and out through the femoral vein (Figure 1D; Supplementary material online, Figure S2). A 20 and 14 mm Amplatzer vascular occluder device was sequentially advanced through the shuttle sheath and deployed with mild–moderate residual MR (Figure 1E; Supplementary material online, Videos S1 and S2). Haemodynamics showed V-wave improvement from 50 mmHg pre-procedurally to 11 mmHg at conclusion (Figure 1C and F). The procedure was uncomplicated, and the patient was discharged 1 day later.

This is the first report of a transcatheter closure of a native MV using a novel arteriovenous rail through a valved LA-to-LV conduit.

Supplementary material

Supplementary material is available at European Heart Journal – Case Reports.

Consent: The authors confirm that written consent for submission and publication of this image in cardiology including images and associated text has been obtained from the patient in line with COPE guidance.

Funding: None declared.

Data availability

The data underlying this article are available in the article and in its online Supplementary material.