Anson Cheung, Daniel Wong, Jian Ye, John G. Webb, Samuel V. Lichtenstein.
St. Paul's Hospital, Vancouver, BC, Canada.
OBJECTIVE:
Transcatheter valve implantation is a new technology that offers an alternative treatment for high-risk, elderly patients with symptomatic valvular disease, but to date this technology has not been applied to reoperative mitral valve surgery. We describe the first known implantation of a transcatheter transapical mitral valve within a previous mitral bioprosthesis (valve-in-valve) in a human.
METHODS:
The patient was positioned for anterior mini-thoracotomy under general anesthesia, and left ventricular apical access was obtained using standard over the wire techniques. The mitral bioprosthesis was crossed retrograde with a wire, and balloon valvuloplasty performed, using rapid ventricular pacing to abolish cardiac output. A 26 mm cuffed transcatheter valve, crimped over a balloon, was then introduced. Under echocardiographic and fluoroscopic guidance, the transcatheter valve was positioned within the xenograft sewing ring for stability and then deployed during rapid ventricular pacing.
RESULTS:
A high-risk, 80-year old male with patent coronary artery bypass grafts presented with symptomatic mitral bioprosthetic valve dysfunction, with a 17 mm Hg mean mitral gradient across a 25 mm bioprosthesis implanted 7 years prior. He was not a candidate for standard reoperation due to high risk from comorbidities (STS score 20.6%). The patient underwent successful implantation of a transapical transcatheter mitral valve prosthesis, with a reduction in the mitral gradient to 3 mm Hg. The valve functioned satisfactorily and was well seated at 5-week angiographic assessment and repeat echocardiography. Due to preexisting comorbidities, his postoperative course was complicated by multiple organ dysfunction including a stroke 3 days later, and ultimately care was withdrawn after a 7-week hospitalization.
CONCLUSIONS:
Transcatheter transapical mitral valve-in-valve implantation is technically feasible in humans. The short- and long-term results of this procedure require further study to guide appropriate patient selection.
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