Effective percutaneous “edge‐to‐edge” mitral valve repair with mitraclip in a patient with acute post‐MI regurgitation not related to papillary muscle rupture

A 65‐year‐old woman was admitted to our institution for rest dyspnea and hypotension. EKG showed sinus tachycardia with signs of infero‐posterior STEMI. 2D‐echocardiogram showed severe left ventricular systolic dysfunction with a‐ diskynesia of the inferior and posterior walls and severe functional mitral regurgitation (MR). The patient underwent urgent coronary angiography that showed 3‐vessels disease with total occlusion of both first obtuse marginal (OM) branch of the left circumflex artery and right coronary artery (RCA) and critical stenosis of left anterior descending (LAD). Because of extremely high surgical risk, we performed a staged totally percoutaneous approach. First, we reopened the presumed culprit vessels (RCA and OM) and then, after 48 hr, we performed angioplasty of the LAD. Since revascularization provided no significant improvement in respiratory and hemodynamic parameters we performed a percutaneous mitral repair with Mitraclip. MR grade was reduced from severe to trivial with rapid improvement of the respiratory and hemodynamic parameters. The post‐procedural course was uneventful and the patient was discharged 7 days later. At the 30‐day and 6‐month follow‐up the patient remained asymptomatic in NYHA I functional class with no recurrence of MR. Acute MR due to post‐AMI mechanical complications is generally considered a contraindication to MitraClip implantation for several reasons. However, the present report shows that, in selected cases, the Mitraclip system may be successfully used to reduce the severity of acute MR secondary to AMI and may allow to reverse cardiogenic shock and/or refractory pulmonary congestion related to the acute regurgitation. © 2016 Wiley Periodicals, Inc.     

Assessment of tricuspid valve by two‐ and three‐dimensional echocardiography with special reference to percutaneous repair and prosthetic valve implantation procedures

Moderate‐to‐severe tricuspid regurgitation affects approximately 1.6 million people in the United States. An estimated 8000 patients will undergo tricuspid surgery annually, leaving a large number of patients with this condition untreated. Many of these individuals who are not referred for surgery engender a large unmet clinical need; this may be primarily due to the surgical risk involved. In persons who are categorized as high‐risk surgical candidates, percutaneous procedures present a viable alternative. The majority of developmental attention as regards percutaneous approaches has been focused on the aortic and mitral valves recently, but few data are available about the feasibility and efficacy of minimally invasive tricuspid valve treatment. We review the usefulness of two‐ and three‐dimensional echocardiography in the assessment of the tricuspid valve with special reference to recent interest in percutaneous repair and prosthetic valve implantation procedures for severe functional tricuspid regurgitation.     

Retrograde percutaneous aortic valve implantation for critical aortic stenosis.

Recently, a prosthetic aortic valve has been implanted percutaneously in several patients using an antegrade transseptal approach. This has been shown to be feasible and associated with dramatic hemodynamic improvement. We report a retrograde implantation of a percutaneous heart valve (PHV) in an 84-year-old man with critical aortic stenosis and refractory congestive heart failure after difficulties encountered with an initial antegrade approach. While attempting antegrade transseptal implantation of a PHV, the anterior leaflet of the mitral valve was tethered by the guidewire resulting in severe mitral regurgitation and pulseless electrical activity. Cardiac resuscitation was successful. Utilizing a retrograde approach, the PHV was successfully implanted in a stable position below the coronary ostia and well above the mitral valve leaflets. The aortic valve area increased from 0.55 to 1.7 cm2 with only mild paravalvular aortic regurgitation. Despite marked improvement in aortic valve function, the patient died secondary to guidewire-induced mitral valve anterior leaflet laceration, severe mitral regurgitation, and cardiogenic shock. Retrograde implantation of a PHV can be successfully performed with substantial increase in aortic valve area and an acceptable degree of aortic regurgitation. Although the retrograde approach may be associated with greater risk of vascular access site complications, it may be considerably safer by avoiding potential guidewire injury to the mitral valve. Further refinements in technique may establish the retrograde approach as the preferred means of PHV implantation in nonsurgical patients with critical aortic stenosis.     

Urgent mechanical circulatory support and transcatheter mitral valve repair for refractory hemodynamic compromise

Patients presenting with hemodynamic instability attributable to left ventricular systolic dysfunction and concomitant severe mitral regurgitation (MR) are increasingly recognized and pose complex management challenges. Surgical therapy is typically precluded owing to prohibitive mortality. The role of percutaneous mechanical circulatory support in such cases is well established; however, such interventions may be neither sufficient to achieve optimal stability nor prove definitive. The advent of novel catheter‐based mitral repair modalities now offers primary decisive therapeutic intervention. Three cases of cardiogenic shock with severe MR illustrate the salutary hemodynamic and clinical responses to percutaneous mechanical support and valve repair by mitral clip.     

First percutaneous transcatheter aortic valve‐in‐valve implant with three year follow‐up

Objectives: This study was conducted to report the clinical, hemodynamic, and iconographic outcomes of the longest survivor of the global CoreValve experience. Background: Early results of percutaneous heart valve (PHV) implantation for severe symptomatic aortic stenosis (AS) have been encouraging, with mid term survival up to 2 years; however longer durability term is unknown. Although a PHV has been implanted in a degenerated surgical bioprosthesis, the feasibility of a PHV‐in‐PHV has not been demonstrated. Methods: A patient with severe refractory heart failure due to severe aortic regurgitation (AR) and moderate AS, underwent CoreValve prosthesis implantation. The PHV was deployed too proximal into the left ventricular outflow tract, resulting in severe AR through the frame struts. Using the first PHV as a landmark, a second CoreValve was then deployed slightly distal to the first, with trivial residual paravalvular leak. Results: The second CoreValve expanded well with proper function. Transvalvular gradient was 8 mmHg. Both coronary ostia were patent. New mild to moderate mitral regurgitation occurred due to impingement of the anterior mitral leaflet by the first PHV. NYHA functional class improved from IV to II, maintained over the past 3 years. Echocardiography at 3 years showed normal functioning CoreValve‐in‐CoreValve prostheses, without AR or paravalvular leaks. Transvalvular gradient was 10 mmHg. Cardiac CT showed stable valve‐in‐valve protheses with no migration. Conclusion: The CoreValve prosthesis has maintained proper function up to 3 years, with no structural deterioration or migration. Treating mixed aortic valve disease with predominant AR is feasible. The concept as well as durability of the first PHV‐in‐PHV has also been demonstrated. © 2008 Wiley‐Liss, Inc.     

Management of severe aortic regurgitation in a patient with cardiogenic shock using a percutaneous left ventricular assist device and transcatheter occlusion of the failed aortic valve homograft as a bridge to surgical valve replacement

Acute hemodynamic compromise due to severe aortic regurgitation remains a difficult problem. The optimal management strategy and timing of surgery continues to evolve as new technologies become available. Here, we report the case of a young woman presenting with severe regurgitation of an aortic homograft who developed precipitous cardiogenic shock and multi‐organ dysfunction. Her mortality risk with emergent surgery was prohibitive, and no percutaneous valve‐in‐valve device was available. We stabilized her condition by placing an Amplatz‐type Atrial Septal Defect (ASD) occluder across her aortic valve in conjunction with a percutaneous left ventricular assist device as a bridge to surgical valve replacement. She went on to a successful surgery and recovered well. © 2013 Wiley Periodicals, Inc.     

First report of a simultaneous transcatheter mitral valve‐in‐valve and aortic valve replacement in a left ventricular assist device patient

Transcatheter aortic valve replacement is standard of care for patients with severe aortic stenosis at high risk for surgical aortic valve replacement. Although not intended for treatment of primary aortic insufficiency, several transcatheter aortic valve prostheses have been used to treat patients with severe aortic insufficiency (AI), including patients with left ventricular assist devices (LVAD), in whom significant AI is not uncommon. Similarly, transcatheter valve replacements have been used for valve‐in‐valve treatment, in the pulmonary, aortic, and mitral positions, either via a retrograde femoral approach or antegrade transseptal approach (mitral valve‐in‐valve). In this case report, we report an LVAD patient with severe aortic insufficiency and severe bioprosthetic mitral prosthetic stenosis, in whom we successfully performed transfemoral aortic valve replacement and transfemoral mitral valve‐in‐valve replacement via a transseptal approach. © 2017 Wiley Periodicals, Inc.     

Successful percutaneous paravalvular leak closure followed by transfemoral aortic lotus valve‐in‐valve implantation in a degenerated surgical bioprosthesis

Bioprosthesis degeneration is a relevant clinical issue that is increasingly developing with the higher expectancy of life. Its treatment may be further complicated by the presence of paravalvular leaks, which are usually consequence of tissue friability, annular calcification, and infection. The surgical treatment of such complex conditions may be too risky, so percutaneous techniques in selected centers are becoming an attracting option. We report the case of a 65‐year‐old gentleman with a previous aortic valve replacement (Perimount n.25) who was admitted with worsening heart failure and transoesophageal evidence of severe intraprosthetic regurgitation and a large paravalvular leak. Since he was judged at too high risk for surgery, he was treated by a fully percutaneous approach. First, he had his large paravalvular leak closed by implantation of two plugs from both retrograde and anterograde routes (arterial–venous loop created). After one month, he underwent a “valve‐in‐valve” transcatheter aortic valve implantation with a fully repositionable Lotus 23 mm valve, which was able to restore a completely normal aortic valve function and let to a dramatic improvement of his functional status at 6‐month follow‐up (from NYHA IV to NYHA I), when a transthoracic echocardiogram also confirmed the absence of any aortic regurgitation. This case shows how a tailored step‐by‐step fully percutaneous strategy is safe and feasible in high‐risk patients with both bioprosthesis degeneration and large paravalvular leaks. This novel opportunity would need to be better evaluated in properly addressed long‐term clinical studies. © 2016 Wiley Periodicals, Inc.     

Transcatheter aortic valve implantation in a patient with mechanical mitral prosthesis: A lesson learned from an intraventricular clash

We hereby present the case of a patient with severe aortic stenosis who underwent in her previous medical history a mitral valve replacement with a mechanical valve (Omnicarbon 27), and progressively developed a severe aortic stenosis. This patient was judged inoperable and then scheduled for CoreValve Revalving System implantation. Despite a good positioning of the CoreValve, an acute, severe mitral regurgitation developed soon after implantation as a consequence of the impaired movement of the mitral prosthesis leaflet. A condition of cardiogenic shock quickly developed. A good mitral prosthesis function was restored disengaging the CoreValve from the aortic annulus. After few months, the patients underwent successful Edwards‐Sapien valve implantation through the Corevalve. This case strongly demonstrates how much a careful evaluation of the features of the mitral prosthesis and patient anatomy is crucial to select which specific transcatheter bioprosthesis would better perform. © 2013 Wiley Periodicals, Inc.     

Transient Symptomatic Severe Mitral Regurgitation after Electric Cardioversion of Atrial Fibrillation

Introduction: After electric cardioversion (EC), several cases of cardiac stunning with cardiogenic shock have been reported. Several hypotheses have been proposed, including stunning of the left ventricle (LV) and modifications in the LV conformation that could lead to severe mitral regurgitation (MR). We report 2 cases of cardiogenic shock with severe MR after EC for atrial fibrillation (AF). Case 1: A 75‐year‐old man presented with AF. A transesophageal echocardiography before the EC showed moderate MR. Shortly after successful EC, the patient developed a cardiogenic shock. The transthoracic and a transesophageal echocardiography showed severe MR. Four days later, an echocardiography showed recovery of MR to a moderate grade. Case 2: An 85‐year‐old woman with a history of percutaneous aortic valve replacement presented with AF. After EC, she developed a cardiogenic shock. The transthoracic echocardiography showed severe MR. After recovery, the echocardiography showed moderate MR. Discussion: Cardiac stunning after EC is well known and could explain the development of severe MR due to restrictive movement of leaflets. The transient character of the MR favors a functional origin with an alteration in the geometry of the mitral apparatus. Some cases of so‐called “eclipsed MR” are described in the literature, however, independently to electric shocks. Conclusion: In some patients, flash pulmonary edema seems to be due to transient severe functional MR, although the exact underlying physiopathologic mechanism remains unclear. An ischemic origin with papillary muscle dysfunction due to transient low perfusion could also be advocated.     

A rare complication of mechanical aortic valve replacement: Separation in the region of the mitral‐aortic intervalvular fibrosa

A 28‐year‐old man was admitted to our emergency service with a shortness of breath and palpitation. On admission, his blood pressure was high and he was in hypertensive pulmonary edema. His physical examination showed rales in both lungs and pansystolic murmur at mitral focus. His medical history included aortic valve replacement (AVR) because of native aortic valve infective endocarditis. Transthoracic echocardiography (TTE) showed normal functional aortic valve. Color flow imaging demonstrated severe mitral regurgitation with posterior eccentric jet. To examine in detail, transesophageal echocardiography (TEE) and three‐dimensional (3D) echocardiography were performed. TEE disclosed a separation in the subaortic curtain leading to severe mitral regurgitation from the left ventricle to the left atrium. In addition to severe mitral regurgitation with posterior eccentric jet, 26‐mm‐long pouch was seen in mitral‐aortic intervalvular fibrosa (MAIVF) at 120° TEE view. This pouch was separated from the mitral anterior leaflet junction releasing the mitral anterior leaflet and causing prolapse and chorda rupture in the A2 scallop of the mitral anterior leaflet. The MAIVF connects the anterior mitral leaflet to the posterior portion of the aortic annulus. The separation of the MAIVF represents a complication of the aortic valve replacement.     

Percutaneous left ventricular support in cardiogenic shock and severe aortic regurgitation

Severe aortic regurgitation (AR) is a well‐established contraindication to intra‐aortic balloon counterpulsation therapy. We report two cases of medically refractory cardiogenic shock in patients with severe AR who were successfully bridged to surgical left ventricular assist device implantation by percutaneous left atrial to femoral artery mechanical bypass. Further investigation into the clinical utility of percutaneous mechanical support in the setting of AR and shock is required. © 2012 Wiley Periodicals, Inc.     

Three‐Dimensional Echocardiographic Delineation of an Acquired Aorto‐Left Atrial Fistula Complicating Native Aortic Valve Endocarditis – “Advantage of Three Dimensions”

Aorto‐atrial fistulas are rare, but important complications resulting from aortic valve infective endocarditis, aortic valve surgery, or aortic dissection. We hereby report a case of a 20‐year male, referred to us with infective endocarditis of the native aortic valve with severe aortic regurgitation and symptoms of heart failure. Detailed evaluation with two‐dimensional and three‐dimensional transthoracic echocardiography revealed aorto‐left atrial fistula secondary to the involvement of the mitral–aortic intervalvular fibrosa (MAIVF) region. The patient underwent successful removal of the vegetations, closure of the defect along with aortic valve replacement, and mitral valve repair.     

Emergent transcatheter mitral valve‐in‐valve implantation in a patient with cardiogenic shock secondary to a failed mitral bioprosthesis

Transcatheter valve‐in‐valve (VIV) implantation is emerging as a therapeutic option for treatment of failed bioprosthesis in patients that are deemed high‐risk or inoperable for redo‐valve replacement. It can be carried out in suitable bioprosthetic valves in any position and usually performed as an elective or semi‐elective procedure. Here, we report a case of emergent transcatheter VIV implantation in a failed mitral bioprosthesis in a critically ill patient with cardiogenic shock. We conclude that transcatheter VIV implantation may also be an option for critically ill patients with failing bioprosthesis. © 2015 Wiley Periodicals, Inc.     

Incremental Value of Three‐Dimensional Transthoracic Echocardiography in the Assessment of Ruptured Aneurysm of Anterior Mitral Leaflet

The mitral valve aneurysm is a rare complication of infective endocarditis involving mitral or aortic valve. The perforation of the mitral valve aneurysm can lead to significant mitral regurgitation (MR) or thromboembolism, which can cause sudden hemodynamic deterioration. We describe here a case of healed infective endocarditis of the aortic valve with ruptured mitral valve aneurysm that led to severe MR. The aneurysm of the anterior mitral leaflet was diagnosed by two‐dimensional transthoracic echocardiography. In this case, three‐dimensional transthoracic echocardiography demonstrated the detailed morphology of mitral valve aneurysm which resulted in successful surgical repair of the aneurysm.     

Severe mitral regurgitation and biventricular heart failure successfully treated with biventricular percutaneous axial flow pumps as a bridge to mitral valve surgery

Prompt recognition of acute right ventricular failure is essential in order to provide timely hemodynamic support. We report a case of a patient with severe mitral regurgitation complicated by cardiogenic shock that failed to improve with left ventricular support alone. The recognition of concomitant right ventricular failure led to the addition of a right ventricular support device, resulting in dramatic hemodynamic improvement. © 2016 Wiley Periodicals, Inc.     

Cleft mitral leaflets and severe mitral regurgitation: Testing the limits of percutaneous mitral valve repair

Repair of mitral regurgitation (MR) with the MitraClip device (Abbot Vascular, Menlo Park, CA) to treat degenerative MR is associated with improved acute and long‐term outcomes. There is an increasing adoption of the device and operators are now testing the limits of the therapy even for unfavorable anatomies. Isolated cleft mitral leaflets are rare but represent a challenge to percutaneous repair. We present two cases of successful repair of severe MR and cleft mitral leaflets. In the first case, a 52‐year‐old male with a dilated cardiomyopathy and an ejection fraction (EF) of 15% presented in decompensated heart failure. Workup revealed a pseudo‐cleft anterior mitral leaflet and a cleft posterior leaflet. A strategy to treat the restricted posterior leaflet lateral of the posterior cleft with a provisional second clip resulted in trace residual MR with only one clip, and an EF improvement to 50% at 2‐month follow‐up. In the second case, an 80‐year‐old male with a history of obstructive CAD with a normal EF but severe MR and a restricted anterior leaflet presented with severe shortness of breath. An initial strategy to grasp the middle of the valve was unsuccessful due to the cleft. Instead, two clips were placed side‐by‐side on either side of the cleft resulting in trivial residual MR. Despite challenging anatomy percutaneous repair can allow for dramatic reduction in MR, resulting in significant left ventricular remodeling and improvement of EF and cardiac output.     

Perceval sutureless valve migration treated by valve‐in‐valve with a CoreValve Evolut Pro

In the last years, the use of sutureless devices in frail patients with severe aortic stenosis has increased thanks to their “easier and faster” technique of implantation in comparison to conventional surgery. Results from metanalysis show comparable outcomes in comparison to transcatheter aortic valve replacement (TAVR) in terms of mortality, stroke incidence, and rate of pace‐maker implantation. The incidence of para‐valvular leak (PVL) is even lower for sutureless devices than for TAVR. The few cases described are generally due to incomplete decalcification or incorrect valve sizing and consequent stent distortion. To our knowledge this is the first case describing PVL with massive aortic regurgitation due to early partial embolization of a Perceval valve and its successfully treatment with valve‐in‐valve by using a self‐expanding TAVR device.     

Valve‐in‐valve implantation with a 23‐mm balloon‐expandable transcatheter heart valve for the treatment of a 19‐mm stentless bioprosthesis severe aortic regurgitation using a strategy of “extreme” underfilling

We report a case of valve‐in‐valve (ViV) implantation by transfemoral approach with a 23‐mm balloon‐expandable prosthesis inside a stentless 19‐mm acutely degenerated bioprosthesis, using a strategy of “extreme” underfilling. A 74‐year‐old patient presented to our institution in cardiogenic shock. An initial transesophageal echocardiography (TEE) showed severe central aortic regurgitation (AR) due to a torn leaflet. She was deemed inoperable and considered for urgent transcatheter aortic valve replacement. Given the fairly small true internal diameter, a strategy of 3‐cc underfilling of a 23‐mm transcatheter heart valve (THV) was planned. However, the final implantation was performed with 5‐cc underfilling due to the incapacity to deliver the entire amount of fluid contained in the inflation syringe. TEE guidance confirmed the successful positioning and deployment of the prosthesis, with no AR and a mean gradient of 25 mm Hg. While implantation of a smaller prosthesis (20 mm) was debated during the Heart Team discussion, the risk of valve embolization due to inadequate anchoring inside the stentless prosthesis led to the selection of a 23‐mm THV. At 6‐month follow‐up, the patient was in NYHA class I, with no AR and a mean gradient of 28 mm Hg. We report for the first time the use of in vivo THV with 5‐cc underfilling with no acute or short‐term structural failure, and the first ViV implantation by transfemoral approach with a 23‐mm balloon‐expandable prosthesis inside a stentless 19‐mm bioprosthesis. The current report presents the challenges related to ViV implantation inside a small stentless bioprosthesis and offers practical ways to overcome them. © 2014 Wiley Periodicals, Inc.     

Transcatheter Aortic Valve Replacement for Severe Aortic Regurgitation With Acute Refractory Cardiogenic Shock

From January 2013 to January 2017, 686 consecutive patients were referred to our centre for transcatheter aortic valve replacement, including 5 subjects with severe aortic regurgitation and acute refractory cardiogenic shock. These patients were contraindicated for surgical treatment by the heart team because of high surgical risk (median logistic EuroSCORE: 74.6/Society of Thoracic Surgeons score: 37.9). The success rate of valve implantation was 100% through transfemoral access with self-expandable devices. The observed 30-day mortality rate was 20%. Hence, the transcatheter aortic valve replacement procedure might represent a successful and life-saving intervention for treatment of patients with severe aortic regurgitation who present with acute refractory cardiogenic shock.