Short-Term Results of Transapical Transcatheter Mitral Valve Implantation for Mitral Regurgitation

Background

Mitral regurgitation (MR) is the most common valvular heart disease, and mitral valve surgery is the gold standard therapy for severe MR. Many patients with severe MR are not referred for surgery because of old age, comorbidities, or severe left ventricular dysfunction. Transcatheter mitral valve implantation may be a better therapeutic option for these high-risk patients with severe symptomatic MR.

Objectives

This study sought to describe the first-in-man series of transapical mitral valve implantation for mitral regurgitation with the TIARA device.

Methods

Extensive preclinical ex vivo and animal studies were conducted with the transapical mitral valve implantation of the Tiara system. The first 2 cases of human implantation were successfully performed in a 73-year-old man and a 61-year-old woman with severe functional MR. Both patients were in New York Heart Association class IV heart failure with depressed left ventricular ejection fraction, pulmonary hypertension, and additional comorbidities.

Results

The valve was implanted uneventfully in both patients. General anesthesia and transapical access were used. Patients were hemodynamically stable with no need for cardiopulmonary bypass. Immediately after implantation, systemic arterial pressure and stroke volume increased and pulmonary pressure decreased dramatically. There were no intraoperative complications, and both patients were extubated in the operating room. Post-procedural echocardiograms at 48 h, 1 month, and 2 months demonstrated excellent prosthetic valve function with a low transvalvular gradient and no left ventricular outflow tract obstruction. There was a trivial paravalvular leak in the first patient at 48 h, which was completely resolved at subsequent studies; no paravalvular leak occurred in the second patient.

Conclusions

Transapical transcatheter mitral valve implantation is technically feasible and can be performed safely. Early hemodynamic performance of the prosthesis was excellent. Transcatheter mitral valve implantation may become an important treatment option for patients with severe MR who are at high operative risk.     

Three‐Dimensional Transesophageal Echocardiography Assessment of a Successful Transcatheter Mitral Valve in Valve Implantation for Degenerated Bioprosthesis

Reoperation for degenerated mitral bioprosthesis is considered a high risk procedure. Transcatheter mitral valve in valve implantation has emerged as an off‐label alternative for patients contra‐indicated to surgery. We report a 46‐year‐old man, with a 29 mm mitral bioprosthesis since 2002, who was admitted for acute heart failure because of a severe intra‐prosthetic regurgitation. His recent medical history revealed a fast growing cavum carcinoma. In view of generally poor prognosis, the heart team decided to perform a transcatheter mitral valve in valve implantation by transapical approach. Live three‐dimensional TEE was used during the implantation for sizing, device positioning, and hemodynamic assessment.     

Combined Transapical Valve-in-Valve/Valve-in-Ring Transcatheter Mitral Valve Implantation and Paravalvular Leak Closure for Failed Mitral Valve Surgery

Recurrent mitral regurgitation (MR) after mitral valve repair or replacement is associated with adverse outcomes. MR may be transvalvular, paravalvular/para-ring, or both, and careful evaluation with transesophageal echocardiography is required. Often patients have high risk of morbidity or mortality, and transcatheter therapies are emerging as an alternative to reoperation. We present 2 cases of complex recurrent MR treated by a transapical transcatheter approach and discuss important clinical and technical considerations.     

经导管二尖瓣植入术的进展

二尖瓣关闭不全是最为常见的瓣膜疾病之一。近年来,介入技术在经导管二尖瓣置换方面取得了巨大进展。国内外目前已有Tiara等5种介入二尖瓣系统成功应用于临床,并有少量病例报道,同时有近20家公司和医疗机构进行相关器材和设备的研发,初步的研究结果显示具有良好安全性和有效性。虽然仍有一些尚待解决的问题,相信随着研究的深入,经导管二尖瓣置换必将逐步走向成熟,在治疗二尖瓣关闭不全上取得新的突破,为更多的患者提供一种微创、有效、安全的治疗手段。本文针对经导管二尖瓣植入术的可行性、安全性等方面进行全面综述。     

Transseptal Mitral Valve Replacement after Transcatheter Aortic Valve Implantation

We report a case of mitral valve replacement in a patient who had previously undergone transcatheter aortic valve implantation. A transseptal approach was used to avoid displacing the aortic prosthesis. Because of the small mitral annulus, a bioprosthetic aortic valve was used in reverse position for mitral valve replacement. The procedure did not interfere with the existing prosthesis, and a follow-up echocardiogram showed that both prosthetic valves were functioning well.To the best of our knowledge, this is the first report of mitral valve replacement in a patient who had a preceding transcatheter aortic valve implantation. We believe that the transseptal approach is promising for mitral valve replacement in such patients. Moreover, using a bioprosthetic aortic valve in reverse position is an option for mitral valve replacement when the mitral annulus is too small for placement of a standard bioprosthetic mitral valve.Key words: Aged, 80 and over; aortic valve; bioprosthesis; calcinosis/complications; cardiac surgical procedures; heart atria/surgery; heart valve prosthesis implantation; mitral valve insufficiency/surgeryTranscatheter aortic valve implantation (TAVI) is currently emerging as a valuable option to treat high-risk patients with severe, symptomatic aortic stenosis.¹ The number of patients receiving TAVI has increased dramatically over a short period of time because of the promising advances in this new technology and the growing number of high-risk, elderly patients with multiple comorbidities, who are better suited for a minimally invasive procedure. Consequently, cardiac surgeons must care for an increasing number of patients who have undergone TAVI. Subsequent cardiac procedures in the setting of previous TAVI pose a challenge due to the risks of procedural interference with—and postprocedural functional impairment of—the previous aortic prosthesis. The following case illustrates an effective method of performing a mitral valve replacement in the setting of previous TAVI.     

Valve-in-Valve-in-Valve Transcatheter Aortic Valve Implantation to Treat a Degenerated Surgical Bioprosthesis in a Subaortic Position

Transcatheter aortic valve implantation for aortic stenosis has evolved as an alternative treatment for patients who are at high or excessive surgical risk. We report the case of an 84-year-old man with a degenerated surgically implanted valve in a subaortic position (9 mm below the native annulus) who underwent “valve-in-valve” transcatheter aortic valve implantation with use of a Medtronic CoreValve system. We planned to deploy the CoreValve at a conventional depth in the left ventricular outflow tract; we realized that this might result in paravalvular regurgitation, but it would also afford a “deep” landing site for a second valve, if necessary. Ultimately, we implanted a second CoreValve deep in the left ventricular outflow tract to seal a paravalvular leak. The frame of the first valve—positioned at the conventional depth—enabled secure anchoring of the second valve in a deeper position, which in turn effected successful treatment of the failing subaortic surgical prosthesis without paravalvular regurgitation.Key words: Aortic valve insufficiency/surgery, bioprosthesis, heart valve prosthesis implantation/instrumentation/methods, intention-to-treat analysis, reoperation/methods, risk assessment, treatment outcomeTranscatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement for the treatment of aortic stenosis in patients who are at high or excessive operative risk.¹ It has been shown that implanting a transcatheter valve within a failing surgical valve (“valve-in-valve”) is safe and effective.² However, the feasibility of this intervention for failing valves in subaortic position has not been reported. The implantation of a self-expandable transcatheter valve at a deep level in the left ventricular outflow tract (LVOT) (with inflow portion >8 mm below the noncoronary cusp) could expectedly be associated with an increased risk of paravalvular regurgitation, valve dislodgment, or both, because of insecure anchoring of the prosthesis in the lower anatomic structures of the LVOT.³ We report the case of a patient in whom we implanted 2 CoreValve® devices (Medtronic, Inc.; Minneapolis, Minn), to safely replace a failing surgical bioprosthesis in a subaortic position.