Hybrid Surgery for Severe Mitral Valve Calcification: Limitations and Caveats for an Open Transcatheter Approach

Background and Objectives: Mitral stenosis with extensive mitral annular calcification (MAC) remains surgically challenging in respect to clinical outcome. Prolonged surgery time with imminent ventricular rupture and systolic anterior motion can be considered as a complex of causal factors. The aim of our alternative hybrid approach was to reduce the risk of annual rupture and paravalvular leaks and to avoid obstruction of the outflow tract. A review of the current literature was also carried out. Materials and Methods: Six female patients (mean age 76 ± 9 years) with severe mitral valve stenosis and severely calcified annulus underwent an open implantation of an Edwards Sapien 3 prosthesis on cardiopulmonary bypass. Our hybrid approach involved resection of the anterior mitral leaflet, placement of anchor sutures and the deployment of a balloon expanded prosthesis under visual control. Concomitant procedures were carried out in three patients. Results: The mean duration of cross-clamping was 95 ± 31 min and cardiopulmonary bypass was 137 ± 60 min. The perioperative TEE showed in three patients an inconspicuous, heart valve-typical gradient on all implanted prostheses and a clinically irrelevant paravalvular leakage occurred in the anterior annulus. In the left ventricular outflow tract, mild to moderately elevated gradients were recorded. No adverse cerebrovascular events and pacemaker implantations were observed. All but one patient survived to discharge. Survival at one year was 83.3%. Conclusions: This “off label” implantation of the Edwards Sapien 3 prosthesis may be considered as a suitable bail-out approach for patients at high-risk for mitral valve surgery or deemed inoperable due to extensive MAC.

Renal and hepatic function of patients with severe tricuspid regurgitation undergoing inferior caval valve implantation

Due to progressive abdominal-venous congestion severe tricuspid regurgitation (TR) is a common cause of cardiorenal and cardiohepatic syndrome. We initiated the TRICAVAL study to compare interventional valve implantation into the inferior vena cava (CAVI) versus optimal medical therapy (OMT) in severe TR. In the present subanalysis, we aimed to evaluate the effects of CAVI on clinical signs of congestion, renal and hepatic function. TRICAVAL was an investigator-initiated, randomized trial. Twenty-eight patients with severe TR were randomized to OMT or CAVI using an Edwards Sapien XT valve. Probands who completed the 3-month follow-up (CAVI [n = 8], OMT [n = 10]) were evaluated by medical history, clinical examination, and laboratory testing at baseline, 3 and 12 months. After 3 months, the CAVI group exhibited a significant reduction of body weight (from 80.7 [69.0–87.7] kg to 75.5 [63.8–84.6] kg, p < 0.05) and abdominal circumference (from 101.5 ± 13.8 cm to 96.3 ± 15.4 cm, p ≤ 0.01) and a trend to lower doses of diuretics compared to OMT. Renal and hepatic function parameters did not change significantly. Within a short-term follow-up, CAVI led to an improvement of clinical signs of venous congestion and a non-significant reduction of diuretic doses compared to OMT.

Transcatheter Aortic Valve Dislocation into the Left Ventricle Caused by the Watermelon Effect

Transcatheter aortic valve implantation (TAVI) is a well-established method for treating severe aortic stenosis. Prosthetic valve dislocation immediately after deployment is a rare and feared complication. We present a case of a patient with severe, symptomatic aortic stenosis who was admitted for TAVI. During balloon inflation the valve (Edwards SAPIEN XT) dislocated into the left ventricle as a result of the watermelon effect caused by a narrow, severely calcified sino-tubular junction. A second valve of the same type and size was immediately implanted in a suboptimal position in order to reduce severe aortic regurgitation. This facilitated the use of veno-arterial extracorporeal membrane oxygenation support (V-A ECMO). The patient was thereafter stabilized and transferred for urgent surgery, where both prosthetic valves were removed. The aortic valve was replaced with an additional reconstruction of the ascending aorta.

Feasibility of coronary angiography after TAVR

Background The prevalence of coronary artery disease (CAD) is high among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR). Indications for TAVR are now expanding to younger and lower risk patients. During their lifetime, these patients will be at risk of developing CAD and it is expected an increase in coronary angiography and percutaneous coronary intervention (PCI). Aortic prosthesis, particularly if in supra-annular position, may pose important technical difficulties in coronary re-engagement after TAVR. Purpose To evaluate the feasibility to reengage the coronary ostia after TAVR, describe complications and compare technical differences between coronary procedures performed before and after TAVR. Methods Retrospective analysis of 714 patients submitted to TAVR from August 2007 to December 2019. Patients who needed coronary angiography after TAVR were selected. The primary endpoint was the rate of successful coronary ostia cannulation after TAVR, defined by the possibility to selectively cannulate and inject both coronary ostia. Secondary endpoint was complications associated with coronary catheterization after TAVR. Results Among 714 patients, 25 (3.5%) patients were submitted to a total of 28 coronary angiography after TAVR. 14 patients were male (56%), mean age 78.2±6.2 years and 9 (36%) had history of previous coronary revascularization. From the 28 coronary angiographies (balloon-expandable Edwards-Sapien n=11, 44%; self-expandable CoreValve n=10, 40%; Portico n=2, 8%; Symetis n=2, 8%), 25 (89%) met the primary endpoint. Only three was semiselective (Symetis, CoreValve Evolut R and CoreValve TAVR in TAVR), with impossibility to cannulate both coronary arteries, right coronary artery and left coronary artery, respectively. 13 (46%) patients had also indication for PCI and all were successfully performed (Edwards-Sapien n=4, 31%; CoreValve n=6, 46%; Portico n=2, 15%; Symetis n=1, 8%). The main indications for coronary angiography was chronic coronary syndrome (n=12, 43%) and acute coronary syndrome without ST segment elevation (n=7, 25%). Circumflex artery was the most frequently treated vessel (n=6), followed by left anterior descending artery (n=4), right coronary artery (n=3) and left main (n=2). There were no complications reported during or post-procedure. Comparing coronary angiographies before and after TAVR, there were no significant differences regarding arterial access site, catheter diameter, fluoroscopy time and quantity of contrast used in coronary angiography. Conclusion Although the need for coronary angiography was rare in patients after TAVR, selective diagnostic coronary angiographies were possible in 89% (25/28) and PCI was feasible in all patients in whom it was indicated, without any reported complications. Further prospective studies are needed to confirm the great feasibility of performing coronary angiography after TAVR. FUNDunding Acknowledgement Type of funding sources: Public hospital(s). Main funding source(s): Centro Hospitalar Vila Nova de Gaia / Espinho

The rescue snared wire technique for challenging transcatheter pulmonary valve implantation: a case series of two patients

Background Transcatheter pulmonary valve implantation (TPVI) is an effective treatment for right ventricular outflow tract (RVOT) dysfunction. Patients affected by congenital heart disease requiring TPVI may have difficult anatomies, thus making the intervention technically demanding. Case summary We report a case series of two patients affected by RVOT dysfunction. Both the cases were characterized by difficulty to advance the valve over the wire, which was successfully overcome by the application of the snared wire technique (SWT) to TPVI. Discussion Various technical pitfalls and tips have been described to facilitate the delivery of the transcatheter Edwards Sapien valve in the pulmonary position. The SWT described by the authors may be a helpful tool to gain supportiveness and stability of the guidewire during the procedure.