Abstract
Severe mitral regurgitation and stenosis due to failed mitral annuloplasty ring can be managed with percutaneous mitral valve in ring in high surgical risk patients. A 66-year-old male underwent coronary artery bypass surgery and mitral valve ring annuloplasty 7 years previously. He started to have shortness of breath with minimal effort in the past 2 years. Transthoracic echocardiogram revealed a new severe mitral regurgitation and severe mitral stenosis. The patient was turned down from surgery due to high surgical risk. The transcatheter mitral valve in ring implantation was decided. In this case, there was a low probability of left ventricular outflow tract obstruction. A stiff wire crossed the mitral valve ring and positioned in the left ventricular apex. The Sapien 3 valve size 26 mm (Edwards Lifesciences, Irvine, CA, USA) was positioned to have 80% ventricular and 20% atrial side. Transesophageal echocardiogram evaluation revealed a mean gradient of 5 mmHg. The left ventricular outflow tract (LVOT) had laminar color flow and the mean pressure gradient across LVOT was 1 mmHg. The patient was discharged after 2 days in good condition. At one year follow up, he had no shortness of breath and no rehospitalization. In conclusion, the percutaneous mitral valve in ring is feasible in selected patients. The risk of LVOT obstruction should be assessed carefully before the procedure with a transthoracic and transesophageal echocardiogram.
〈Learning objective: Understand how to guide the mitral valve in ring procedure with a transesophageal echocardiogram and how to avoid left ventricular outflow tract obstruction. Understand how to position the Sapien valve in mitral valve ring.〉
Keywords: Mitral valve, Mitral regurgitation, Valve in ring, Transcatheter, Case report
Introduction
Progressive remodeling of the left ventricle with a lateral and apical displacement of one or both papillary muscles can lead to failure of the annuloplasty ring with severe mitral regurgitation [1]. Also, progressive degeneration of mitral valve leaflets in the presence of a mitral valve ring can lead to significant mitral stenosis. If the patient is at high-risk for redo-surgery, percutaneous treatment approaches are good alternatives and associated with good peri-interventional success [2]. The 2017 update of the American Heart Association/American College of Cardiology guideline for the management of patients with valvular heart disease changed the word reoperation to reintervention considering the transcatheter valves [3]. In the presence of significant mitral stenosis, the only percutaneous option is Sapien valve (Edwards Lifesciences, Irvine, CA, USA) in mitral valve ring. The MitraClip (Abbott, Abbott Park, IL, USA) can work in isolated severe mitral regurgitation especially if the annuloplasty ring is too large for implantation of a Sapien prosthesis [4]. We report a case of transcatheter mitral valve implantation in failed annuloplasty ring with severe mitral stenosis and mitral regurgitation. We highlight the role of a transesophageal echocardiogram in guiding this procedure.
Case report
A 66-year-old male known to be hypertensive and diabetic on insulin for the previous 20 years presented with non-ST-elevation myocardial infarction 7 years previously. At that time, his transthoracic echocardiogram showed ischemic cardiomyopathy with ejection fraction 35% and severe posteriorly directed ischemic mitral regurgitation. His coronary angiography revealed multivessel disease. He underwent coronary artery bypass grafts and mitral valve ring annuloplasty using Carbomedics Annuloflex Sorin C-shaped ring (Sorin, Milan, Italy). He did well on regular follow up for the following 6 years. His follow-up transthoracic echocardiogram 5 years post-surgery showed a well-functioning ring with no mitral regurgitation (Fig. 1A and Video 1). He started to experience shortness of breath with minimal effort New York Heart Association class III in the past 2 years with a progressive course.
Fig. 1.
(A) Transthoracic echocardiogram post surgery, the mitral valve was functioning well with no mitral regurgitation. (B) Transesophageal echocardiogram showed severe mitral regurgitation, posterior jet, left ventricular outflow tract (LVOT) diameter 23 mm (short arrow), the anterior mitral leaflet to LVOT distance 18 mm. (C) The angle between the LVOT trajectory and the left ventricular long axis where the implanted valve will be positioned is 70°. (D) 3D full volume with color confirmed the severe mitral regurgitation. (E) The mean pressure gradient across mitral valve was 19 mmHg indicating also severe mitral stenosis. (F) Systolic reversal in the left upper pulmonary vein.
Investigations
Transthoracic echocardiogram revealed a new severe mitral regurgitation, posterior jet, left ventricular outflow tract (LVOT) diameter 23 mm, the anterior mitral leaflet to LVOT distance 18 mm (Fig. 1B and Video 2). The angle between the LVOT trajectory and the left ventricle long axis where the implanted valve would be positioned was 70° (Fig. 1C). Three-dimensional full volume echocardiography with color confirmed the severe mitral regurgitation (Fig. 1D and Video 3). The mean pressure gradient across the mitral valve was 19 mmHg indicating also severe mitral stenosis (Fig. 1E). A clear systolic reversal in the left upper pulmonary vein supported the mitral regurgitation severity (Fig. 1F). There were mild tricuspid regurgitation and severe pulmonary hypertension with systolic pulmonary artery pressure 90 mmHg. Computed tomography showed patent grafts. The heart team turned down the patient from surgery because he was a high surgical risk. The transcatheter mitral valve in ring implantation was decided.
Procedure description
The planned procedure was transseptal mitral valve implantation of a balloon-expandable valve SAPIEN 3, size 26 mm. This size was selected based on the true internal diameter of the ring with transesophageal echocardiography, 24 mm diameter is suitable for a 26-mm valve. The manufacturer's web site recommended a 26-mm valve for this Carbomedics Annuloflex Sorin C-shaped ring. In a standard catheterization laboratory, under general anesthesia with transesophageal echocardiogram guidance, right femoral arterial and venous accesses, and left venous access 6F for pacemaker lead as a backup was established. The transesophageal echocardiogram had an important role to predict the possibility of LVOT obstruction post valve implantation. In this case, there was a low probability of LVOT obstruction as evidenced by large LVOT 23 mm, no basal septal bulge, and LVOT LV angle was acute at 70° (Fig. 1B and C). Transseptal access was established. Intravenous heparin 100 IU/kg was given (activated clotting time target 250–300 s throughout the procedure). A 14-mm balloon was used to dilate the interatrial septum (Fig. 2A and Video 4). A stiff pre-shaped 0.035 inches Confida Wire (Medtronic, Minneapolis, MN, USA) crossed the mitral valve ring and was positioned in the LV apex (Fig. 2B and Videos 5 and 6). An Edwards E-sheath 14F was introduced through the right femoral vein to the level of hepatic veins, the Sapien 3 valve size 26 mm crossed to the left atrial cavity with the Edward mark upside down. After the valve delivery system crossed the mitral valve ring, the Sapien valve balloon was inflated without rapid pacing very slowly to allow for fine positioning targeted on 80% ventricular and 20% atrial positioning of the mitral valve ring (Fig. 2C and D and Videos 7–9). Transesophageal echocardiogram evaluation revealed a mean gradient of 5 mmHg with no valvular or paravalvular incompetence. The LVOT had laminar color flow (Fig. 2E and Video 10) and the trans-gastric long-axis view to aorta showed the well-positioned valve in ring and the opened LVOT (Fig. 2F). The mean pressure gradient across LVOT was 1 mmHg (Fig. 3A). Diastolic and systolic three-dimensional zoom frames in surgical view showed the tri-leaflet implanted valve in ring that was fully opened in diastole. A usual residual atrial septal defect was a small left to right shunt that did not require any intervention.
Fig. 2.
(A) 14-mm balloon dilation of interatrial septum, note the C shaped mitral valve ring. (B) 3D zoom surgical view showed the trans-septal wire (arrow) passed the mitral valve ring to left ventricle. (C) The valve positioned 80% ventricular and 20% atrial and deployed. (D) The 26-mm valve deployed inside the mitral valve ring. (E) Transesophageal echocardiogram (TEE) left ventricular outflow tract (LVOT) view at 130° after valve in ring deployment showed laminar flow at LVOT. (F) TEE transgastric long-axis view to aorta showed the valve in ring (long arrow) and opened LVOT (short arrow).
Fig. 3.
(A) The mean pressure gradient at the left ventricular outflow tract post valve in ring is 1 mmHg. (B) Diastolic frame 3D zoom in surgical view showed the fully opened tri-leaflet implanted valve in ring. (C) Systolic frame 3D zoom in surgical view showed the tri-leaflet implanted valve in ring. (D) Follow up transthoracic echocardiogram, parasternal long-axis view showed the well-functioning transcatheter mitral valve replacement.
The patient was discharged after 2 days in a good condition on anti-failure medications and a small dose of furosemide. He returned to his normal daily activity after one month. At one year follow up, he had no shortness of breath and no rehospitalization. His follow up transthoracic echocardiogram showed normal functioning valve with normal LVOT pressure gradient (Fig. 3D and Video 11).
Discussion
LVOT obstruction is more commonly reported in transcatheter mitral valve replacement into mitral annuloplasty rings and calcified native mitral valve because of the systolic anterior motion of the anterior mitral leaflet [5]. VIVID registry reported 156 cases of mitral valve in ring, the median age was 71.2 ± 11.8 years. The failure of the ring resulted in severe mitral regurgitation in 62%, severe MS in 17%, and mixed mitral stenosis and mitral regurgitation in 17% [6]. Transesophageal echocardiography was performed in 98% of cases and 97.3% were under general anesthesia. There was moderate plus mitral regurgitation in 19.9%. The VIVID registry concluded that mitral valve-in-ring was associated with worse clinical results in comparison with valve-in-valve, including more post-procedural mitral regurgitation and LVOT obstruction [6]. Almost one-third of patients undergoing valve-in-ring experienced the composite adverse event endpoint at 30 days [6]. In this case, the mitral valve ring failed after 6 years and led to combined mitral stenosis and mitral regurgitation. Cardiac computed tomography can measure the neo-LVOT by direct planimetry but it had many limitations: 1 – The neo-LVOT dimensions are dynamic and dependent on volume and loading conditions. 2 – The predicted valve position assumes that the valve will deploy at the center of the mitral annulus, which does not apply in reality [7]. 3 – The displacement of the native anterior mitral valve leaflet plays a role in LVOT obstruction, which is not assessed on computed tomography [8]. The risk for LVOT obstruction increased in small baseline LVOT dimensions, the presence of a basal septal bulge, and a large angle between the trajectory of the existing bioprosthesis and the aortic root [9]. We think that transesophageal echocardiography is still able to predict the risk of LVOT obstruction based on these data. There are limited data on the durability of mitral valve-in-ring [10]. Additional prospective, multicenter, longitudinal research is essential to better understand the long-term risks and benefits of transcatheter mitral valve replacement in mitral valve ring.
Conclusion
The percutaneous mitral valve-in-ring is feasible in selected patients. The risk of LVOT obstruction should be assessed carefully before the procedure with transthoracic and transesophageal echocardiogram. A transesophageal echocardiogram is mandatory for valve sizing and procedure guidance.
Author contributions
Hesham Abdo Naeim was the echocardiographer during the procedure and wrote the manuscript. Osama Alamodi, cardiology consultant at Madina Cardiac Center, helped in writing the manuscript and language revision. Mohamed Ajaz Ghani, cardiology associate consultant at Madina Cardiac Center, helped in software and data collection. Ahmed Nore Albagi, fellow in cardiology at Madina Cardiac Center, helped in data collection. Reda Abuelatta, cardiology consultant at Madina Cardiac Center, was the senior interventionist who performed the procedure and wrote the procedure details.
Footnotes
Supplementary data associated with this article can be found, in the online version, at https://doi.org/10.1016/j.jccase.2020.05.006.
Appendix A. Supplementary data
The following are the supplementary data to this article:
Transthoracic echocardiogram well-functioning mitral valve ring.
Failed mitral valve ring severe mitral regurgitation.
3D Severe mitral regurgitation, failed mitral valve ring.
C shaped mitral valve ring, 14 mm balloon dilation of interatrial septum.
The wire passed the mitral valve ring and positioned at left ventricular apex.
3D trans-septal wire passed the mitral valve ring to left ventricle.
Deployment of the 26 valve in mitral valve ring.
Deployed 26-mm valve with 80% to left ventricle and 20% to left atrium.
3D zoom deployed 26 valve in mitral valve ring.
Left ventricular outflow tract laminar flow post valve deployment.
One year follow up transthoracic echocardiogram, well-functioning valve, good left ventricular outflow tract.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Transthoracic echocardiogram well-functioning mitral valve ring.
Failed mitral valve ring severe mitral regurgitation.
3D Severe mitral regurgitation, failed mitral valve ring.
C shaped mitral valve ring, 14 mm balloon dilation of interatrial septum.
The wire passed the mitral valve ring and positioned at left ventricular apex.
3D trans-septal wire passed the mitral valve ring to left ventricle.
Deployment of the 26 valve in mitral valve ring.
Deployed 26-mm valve with 80% to left ventricle and 20% to left atrium.
3D zoom deployed 26 valve in mitral valve ring.
Left ventricular outflow tract laminar flow post valve deployment.
One year follow up transthoracic echocardiogram, well-functioning valve, good left ventricular outflow tract.