A 77-year-old woman with symptomatic severe mitral bioprosthetic valve regurgitation was referred for transseptal mitral valve-in-valve implantation. She had no other major comorbidity and no previous psychiatric condition. The mitral valve-in-valve procedure was successfully performed under general anesthesia (fentanyl, propofol, and rocuronium) with a 29-mm Sapien 3 transcatheter heart valve (Edwards Lifesciences LLC, Irvine, CA) implanted within a 33-mm Epic St. Jude surgical valve (Fig. 1A; Video 1
, view video online). No electrocardiogram changes were noted, and the immediate post-implant transesophageal echocardiogram showed a normal left ventricular ejection fraction (LVEF), a mean mitral gradient of 4 mmHg, and no paravalvular leak.
Figure 1.
Fluoroscopic image, electrocardiogram tracing, and left ventriculogram after a 29-mm Sapien 3 transcatheter heart valve (Edwards Lifesciences LLC, Irvine, CA) was implanted within a 33-mm Epic St. Jude surgical valve. (A) Fluoroscopic image of a 29-mm Sapien 3 (white arrow) implanted within a 33-mm Epic St. Jude surgical valve (red arrow). (B) Electrocardiogram post-implantation demonstrating new anterior T-wave inversion. (C-D) Left ventriculogram demonstrating apical ballooning.
Despite symptom improvement, a routine day-1 transthoracic echocardiogram revealed new severe antero- and infero-apical hypokinesia, with an estimated LVEF of 25%, and a mean mitral gradient of 5 mmHg without left ventricular outflow tract obstruction (Video 2
, view video online). The electrocardiogram showed new inverted T waves in the anterior leads, and the QTc interval was 492 ms vs 455 ms on the pre-procedure electrocardiogram (Fig. 1B). Peak troponin was 179 ng/L (N < 9 ng/L). An urgent coronary angiogram showed normal coronaries, and the ventriculogram revealed a classical appearance of Takotsubo cardiomyopathy (Fig. 1, C and D; Video 3
, view video online). No psychotropic drug or pressors had been administrated either pre- or per procedure. The in-hospital course was uneventful, and the patient was discharged at day 3. The QTc interval was 480 ms on the discharge electrocardiogram. At 1-month follow-up, transthoracic echocardiography showed complete left ventricular recovery to her baseline LVEF (50%-55%; Video 4
, view video online).
Takotsubo cardiomyopathy was suspected in light of the following: (i) a new left ventricular wall motion abnormality, including apical ballooning; (ii) normal coronary angiogram; (iii) new electrocardiographic changes and troponin elevation; and (iv) the absence of myocarditis, coronary thrombus, or air embolism.
Stress-induced cardiomyopathy has been reported only rarely following transcatheter valve replacement.1, 2, 3, 4 Takotsubo cardiomyopathy may occur in rare cases following a mitral valve-in-valve procedure, although the mechanism remains unclear.
Novel Teaching Points.
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Takotsubo cardiomyopathy may occur after minimally invasive procedures, including transcatheter mitral valve-in-valve implantation.
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Urgent coronary angiogram is key to ruling out differential diagnosis, including coronary embolism.
Acknowledgments
Funding Sources
The authors have no funding sources to declare.
Disclosures
A.G.C. is funded by the New Zealand Heart Foundation and a John Ormiston Scholarship. J.S. is a consultant to Edwards Lifesciences and Medtronic. M.M. received research grant from Fédération Française de Cardiologie, Biotronik, and Medtronic. D.M. is supported by the Swiss National Science Foundation (grant P2LAP3_199561). J.G.W. is a consultant to Edwards Lifesciences. The other authors have no conflicts of interest to disclose.
Footnotes
Ethics Statement: The research reported has adhered to the relevant ethical guidelines.
See page 353 for disclosure information.
To access the supplementary material accompanying this article, visit CJC Open at https://www.cjcopen.ca/ and at https://doi.org/10.1016/j.cjco.2021.12.006.
Supplementary Material
29mm Sapien 3 transcatheter heart valve implanted within a 33mm Epic St. Jude surgical valve.
Echocardiogram post implant demonstrating severe antero and infero-apical hypokinesia, mean trans-mitral gradient of 5 mmHg without left ventricular outflow tract obstruction.
Coronary angiogram and left ventriculogram.
Echocardiogram 1-month post implant.
References
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Associated Data
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Supplementary Materials
29mm Sapien 3 transcatheter heart valve implanted within a 33mm Epic St. Jude surgical valve.
Echocardiogram post implant demonstrating severe antero and infero-apical hypokinesia, mean trans-mitral gradient of 5 mmHg without left ventricular outflow tract obstruction.
Coronary angiogram and left ventriculogram.
Echocardiogram 1-month post implant.