Pre-Operative Imaging Assessment is Mandatory Prior Structural Transcatheter Procedures: a Case of Minimally Invasive Bail-Out Sapien XT Implantation in Mitral Position-Juniper Publishers



Abstract

Degeneration of bioprosthesis may occur in elderly and frail patients with an extremely high risk for redo cardiac surgery. Transcatheter valve-in-valve procedures represent a valuable treatment option in high-risk patients [1,2]. However incidental findings may contraindicate the transcatheter procedure. We describe the original case of a patient who was scheduled for transapical mitral valve-in-valve, but due to a left atrial mass underwent mini-invasive surgery with successful direct mitral valve-in-valve delivery and excision of the mass.

Keywords: TAVI; Transcatheter; Mitral; Valve-in-valve; Bioprosthesis failure; Minimally invasive surgery

Introduction

Degeneration of bioprosthesis may occur in elderly and frail patients with an extremely high risk for redo cardiac surgery. Transcatheter valve-in-valve procedures represent a valuable treatment option in high-risk patient population [1-3]. Usually before transcatheter valve procedures, patients are studied with CT-scan and/or transesophageal echocardiography in order to estimate the exact anatomical sizes.

Case Report

A 82-years old man with rheumatic heart disease in 2007 underwent mitral valve replacement with a 27mm Carpentier Perimount bioprosthesis (Edwards Life sciences, Irvine, CA, USA) via sternotomy. In January 2015 the patient was admitted for syncope with dizziness and vomiting and worsening of shortness of breath; CT head scan, ear-nose-throat evaluation and Holter ECG were normal. Transthoracic Echocardiography (TTE) showed a 43% left ventricle ejection fraction with severe mitral stenosis (mean gradient 14.5mmHg) and moderate regurgitation, mild tricuspid regurgitation with 69mmHg of Systolic Pulmonary Artery Pressure (Figure 1 and Video 1).


Because of age and frailty of the patient, and the history of previously implanted bioprosthesis, a trans-apical mitral valve-in- valve procedure was indicated. Since we knew the precise size of mitral prosthesis, we did not performed any usual imaging (CT- scan or TEE) to estimate the valvular size.


Unexpectedly intra-operative transesophageal echocardiography revealed the presence of a sessile and compact formation of 2.5 x 1cm, situated between the roof of the left atrium and the atrial septum (Figure 2 and Video 2) that was not detectable on transthoracic echocardiography. Because of the risk of embolization the procedure was switched to open heart surgery through a right anterolateral minithoracotomy at the fourth intercostal space [4]. Cardio pulmonary by-pass through the right femoral artery, the right femoral vein and right jugular vein was established. Under ventricular fibrillation the left atrial mass was quickly removed and a 29mm Sapien XT (Edwards Life sciences, Irvine, CA, USA), mounted on the trans apical delivery system, was easily implanted under direct vision inside 27-mm Carpentier Perimount bioprosthesis. Intraoperative transesophageal echocardiography showed normal transvalvular gradients and a laminar flow (Figure 3 and Video 3). The histologic exam of the mass confirmed the hypothesis of mixoma. The patient was discharged on 6th post-operative day. The one year echocardiographic follow-up is comparable to the one at discharge (Video 4).



Conclusion

Valve-in-valve implantation in mitral position is becoming an increasingly accepted treatment option for patients deemed unsuitable for redo operation [5-8].

This case demonstrates:

    a) The importance of pre-operative imaging assessment (CT thoracic scan and/or transesophageal echocardiography) prior of any structural transcatheter intervention, even if exact anatomical sizes are known; it is not unusual to find other unexpected anatomical surprises.

    b) The easiness of direct mitral valve-in-valve procedure, that to date has been described only once [5].

    c) The efficacy of the procedure after one year. 

Comments

Post a Comment

Popular posts from this blog

Can We Prevent Cardio Vascular Morbidities and Mortalities?-Juniper Publishers

Image
JUNIPER PUBLISHERS - OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY   Opinion Cardivan- vascular dieses are group of disease which are totally preventable, it is concluded that almost 90% of CVD is avoidable. Improving risk factors is the key point in Prevention strategies, thus minimizing atherosclerosis process are significantly linked to improving risk factors by: healthy diet consumption, conducting exercises, eliminating tobacco smoke and educing alcohol intake. Lipids and high blood pressure management and control have great impact on CVD morbidities and mortalities. Applying effective strep throat with suitable antibiotics can contribute to decrease risk of rheumatic heart disease. Cardiovascular diseases kept the main cause of mortality worldwide globally. It has been estimated that the mortality rate has been increased from 17.9 million deaths (32.1%) in 2015, up from 12.3 million (25.8%) in 1990 and have been increasing in much of the developing w
Read more

Spinal Cord Injury: An Under Recognized Cardiovascular Disease Risk Factor-Juniper Publishers

Image
JUNIPER PUBLISHERS - OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY Keywords Keywords: Stroke; Coronary artery disease; Paraplegia; Tetraplegia Opinion Spinal cord injury (SCI) is a devastating, life-changing condition causing paralysis and sensory impairment as well as autonomic dysfunction. In addition, evidence documents a state of chronic inflammation in individuals with SCI [ 1 - 4 ]. Importantly, chronic inflammation is a significant cardiovascular disease risk factor. Furthermore, paralysis can lead to a relatively sedentary life style and a consequent reduction in physical work capacity [ 58 ]. Other consequences of inactivity are a higher body weight, a higher percentage of body fat [ 9 , 10 ], skeletal muscle dysfunction [ 11 - 14 ] and a lower forced vital capacity [ 15 - 17 ]. Autonomic dysfunction involves an abnormal and unstable regulation of the of the heart and vasculature [ 18 ].
Read more

Sudden Heart Pathology-a New Research Hipotesys-Juniper Publishers

Image
JUNIPER PUBLISHERS - OPEN ACCESS JOURNAL OF CARDIOLOGY & CARDIOVASCULAR THERAPY   Keywords Keywords: Cardiology; Heart disease; Diagnostic systems Introduction We can see that heart is usually studied using many diagnostic strategies and under different Mechanism as functions, electric activity, receptorial, imaging, instrumental test, genetic profile, exercise tests, biopsy and so on. But what we can see is that until today in not possible to prevent some unexpected death. So we can think that perhaps we need more diagnostic test to right consider this aspect. Can we use innovative methods to introduce more useful systems? In ischemic condition some test can help to detect the residual heart capacity but can we test in the same way the heart biochemical-metabolic status or pharmacological profile? In a recent case we have see that in a transplant heart procedure was used an organ by a patient death Due to cerebral damage after a heart at
Read more