Failed transcatheter mitral valve-in-ring implantation followed by transapical valve-in-valve within the ring and ad hoc paravalvular leak closure

Introduction

There is a rapid emergence of transcatheter mitral valve-in-valve (TMVIV) and valve-in-ring (TMVIR) techniques as an alternative to the conventional surgical valve replacement in ineligible patients requiring repeat surgery (1).

The selection of a new transcatheter heart valve (THV) for degenerated surgical valves is relatively simple; however, the selection of valves for mitral rings is more nuanced because the rigid oval or D-shaped rings will not conform to the round shape of the prosthesis, thus posing a high risk of paravalvular leak (PVL).

Although prior reports have described simultaneous TMVIV and percutaneous PVL closure techniques, our case report provides the first description of simultaneous transapical valve-invalve implantation and the closure of severe PVL after a failed transseptal valve-in-ring procedure (2, 3).

Case Report

A 64-year-old female with a history of insulin-dependent diabetes, chronic kidney disease, and hypertension, as well as a history of failed mitral ring annuloplasty 15 months ago (30-mm Medtronic 3D mitral ring) was deemed ineligible for the surgery and referred to the cardiology clinic for TMVIR and the treatment of severe mitral regurgitation.

After a transseptal puncture under the guidance of 2D transesophageal echocardiography (TEE) and fluoroscopy, we performed balloon dilatation (12 mm×60 mm) of the septum to facilitate the crossing of the septum. We used an Agilis (Abbott Vascular) steerable sheath of 8.5 F to introduce a 0.035-inch angled hydrophilic wire across the ring with subsequent exchange for stiff wire. Thereafter, we positioned and slowly mounted the center of the 26-mm Sapien XT stent frame (mounted in the opposite direction as performed for transfemoral transcatheter aortic valve implantation) within the ring under rapid pacing. Unfortunately, we were not able to achieve the coaxial deployment of valve in the prior annuloplasty ring (Fig. 1a), thus complicating severe PVL (Fig. 1b) (Video 1). Therefore, we planned paravalvular closure in the same session. However, during this procedure, more dehiscence of the THV from the ring carrying the risk for embolization occurred because of manipulations of catheter (Fig. 1c, 1d) (Video 2), which led to stopping of the procedure without closing the defect.

Figure 1.

(a) Fluoroscopy of Sapien XT in the mitral bioprosthesis with a suboptimal position. (b) The TEE image showing severe PVL after the deployment of the THV; (c) More dehiscence of the THV after failed PVL closure, (d) Delivery system entrapped in the defect

The patient’s hemodynamic status was stable after the first procedure. Transapical TMVIV was scheduled after eight days. We implanted a second 26-mm Sapien XT valve within the previous THV via a coaxial transapical access (Fig. 2a). Nevertheless, persisting severe PVL was still detected even though kissing balloons (20 mm in diameter) were inflated within the valve. Therefore, we deployed 14-mm-long Vascular Plug II (St. Jude Medical, Minneapolis, Minnesota) (Fig. 2b, 2c) (Video 3) within the defect. TEE revealed a competent bioprosthetic valve without residual mitral regurgitation (Fig. 2d) (Video 4). The patient experienced significant symptomatic relief and functional improvement. She remained free from rehospitalization for six months.

Figure 2.

(a) Transapical route to secure the previous bioprosthetic valve. (b, c) Fluoroscopy and TEE images of 14-mm AVP II device deployed in the defect. (d) TEE confirmed no residual PVL after closure

Discussion

Technically, the TMVIR procedure is more challenging than the TMVIV implantation because of the larger diameters and geometric variability of the rings. Unlike the frame of the bioprosthesis, the rings have an oval shape to adapt to the configuration of the implanted valve, thereby having a higher risk of valve embolization and paravalvular regurgitation (4, 5). The risk of obliquity of the THV in the TMVIR procedures is more important than with bioprostheses because of the absence of frame. In our case, once the position of the THV was deemed adequate, we were not able to provide enough coaxiality under rapid ventricular pacing. The native mitral valve leaflets in the failed ring might have also disrupted the anchoring of THV.

The transseptal route also has several advantages, such as less invasiveness and requirement of local anesthesia; however, transapical access allows the TMVIV/TMVIR deployment to be performed coaxially while more simply and potentially reducing malpositioning and associated complications as shown in our case.

The current commercially available THVs could be an imperfect match for the oval saddle-shaped geometry of the mitral annulus and rings, thereby leading to inherent PVL. The conversion to a transapical approach might provide a second THV implantation to secure the first one as well as a more feasible closure of the PVL.

Conclusion

Saddle-shaped rings and transseptal approach might preclude the optimal placement of TMVIR. The currently available occluder and delivery systems are suboptimal and dedicated ones; therefore, a steerable system is needed for the prevention of malalignment. Transapical implantation enables a better control over the implant position and facilitates defect closure.

Supplementary Data

Video 1

Fluoroscopy of the first procedure indicating crossing, malalignment, and displacement of the transcatheter valve during the attempts for paravalvular leak closure.

Video 2

TEE images of the first procedure, wherein central mitral insufficiency turned to severe paravalvular leak after the failure of coaxial placement of the transcatheter valve.

Video 3

Transapical route with persisting paravalvular leak despite kissing balloon inflations after the implantation of the second valve. The defect was closed with 14-mm AVP II.

Video 4

TEE images of the transapical approach that sealed the defect after the deployment of 14-mm AVP II.