JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 7, NO. 12, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcin.2014.06.020
IMAGES IN INTERVENTION
An Unexpected Finding Stuck Leaflet After Transapical Mitral Valve-in-Valve Implantation Augusto D’Onofrio, MD, PHD,* Michele Gallo, MD,* Giuseppe Tarantini, MD, PHD,y Umberto Cucchini, MD, PHD,y Demetrio Pittarello, MD,z Gino Gerosa, MD*
T
ransapical mitral valve-in-valve (ViV) im-
II bioprosthesis (Medtronic, Minneapolis, Minnesota).
plantation was performed in an inoperable
The true internal diameter of the 29-mm Hancock II
patient with a dysfunctional 29-mm Hancock
valve is 24 mm (1), thus a 26-mm Sapien-XT (Edwards
F I G U R E 1 Fluoroscopic Image of Transapical Deployment of the 26-mm Edwards Sapien XT Bioprosthesis
(A) The 26-mm Edwards Sapien XT bioprosthesis is deployed into the stent of the 29-mm Hancock II. Post-deployment fluoroscopic image shows the final result (Online Video 1). (B) The “hour-glass” shape of the Sapien XT valve results from the discrepancy of size between the valves. Intraoperative transesophageal echocardiography shows normal leaflet motion in diastole (C) and in systole (D) with no residual mitral regurgitation.
From the *Division of Cardiac Surgery, University of Padova, Padova, Italy; yDivision of Cardiology, University of Padova, Padova, Italy; and the zDivision of Anesthesiology, University of Padova, Padova, Italy. Dr. D’Onofrio is a transapical aortic valve implantation proctor for Edwards Lifesciences. Prof. Gerosa is a transapical aortic valve implantation proctor for Edwards Lifesciences; and has received speaker’s fees from St. Jude Medical and HeartWire. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
e188
D’Onofrio et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 12, 2014 DECEMBER 2014:e187–9
Leaflet Immobility After Mitral Valve-in-Valve
F I G U R E 2 3D-TEE at 6 and 12 Months
(A and B) Three-dimensional transesophageal echocardiography (3D-TEE) 6 months after the procedure shows a stuck valve leaflet (Online Video 2). After 12 months at 3D-TEE, we observed a similar condition (C and D). (Red asterisk indicates the stuck valve leaflet).
Lifesciences, Irvine, California) valve was implanted
other
(Figures 1A and 1B, Online Video 1). The procedure
deployment and incomplete opening of the Sapien-
possible
mechanisms
include
noncoaxial
was uneventful with no residual mitral regurgitation
XT valve frame as a result of the size discrepancy.
(Figures 1C and 1D). Warfarin was administered for
In particular, in this case, a suboptimal deployment
permanent atrial fibrillation. Pre-discharge echocar-
of the transcatheter valve was observed: fluoroscopy
diography showed a well-functioning Sapien-XT
showed an “hour-glass” shape of the Sapien-XT valve
valve with normal motion of the 3 pericardial leaflets.
because of a too “atrial” final positioning (30% to 35%
At 6-months follow-up echocardiography, 1 of the 3
of the valve on the atrial side of the radiopaque
pericardial leaflets was stuck in the closed position,
marker) rather than a more correct “conical” shape
whereas the other 2 leaflets showed normal motion
(10% to 15% only of the valve on the atrial side) (1,2)
(Figures 2A and 2B, Online Video 2). The same finding
that may also help in preventing atrial migration of
was observed 12 months later (Figures 2C and 2D). The
the valve. Although transapical mitral ViV implanta-
patient is in excellent clinical condition; her New
tion is technically feasible (3,4), stuck valve leaflets
York Heart Association functional class is I at
is a potential complication that implanting physicians
follow-up, and mean transmitral gradient is only 5
should be aware of.
mm Hg. Therefore, we decided to closely monitor the patient with no indications for further invasive
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
treatment unless some changes in her clinical and/
Augusto D’Onofrio, Division of Cardiac Surgery,
or echocardiographic status should occur. Although
Department of Cardiac, Thoracic and Vascular Sci-
no images of valve thrombosis were found, this is
ences, Via Giustiniani 2, 35128 Padova, Italy. E-mail:
the most likely etiology of the stuck leaflet. However,
[email protected].
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 12, 2014 DECEMBER 2014:e187–9
D’Onofrio et al. Leaflet Immobility After Mitral Valve-in-Valve
REFERENCES 1. Bapat VN, Attia R, Thomas M. Effect of valve design on the stent internal diameter of a bioprosthetic valve: a concept of true internal diameter and its implications for the valve-in-valve procedure. J Am Coll Cardiol Intv 2014;7:115–27. 2. Bapat VN, Khaliel F, Ihlberg L. Delayed migration of a Sapien valve following a transcatheter mitral valve-in-valve implantation. Catheter Cardiovasc Interv 2014;83:E150–4.
3. Seiffert M, Conradi L, Baldus S, et al. Transcatheter mitral valve-in-valve implantation in patients with degenerated bioprostheses. J Am Coll Cardiol Intv 2012;5:341–9. 4. Wilbring M, Alexiou K, Tugtekin SM, et al. Transapical transcatheter valve-in-valve implantation for deteriorated mitral valve bioprostheses. Ann Thorac Surg 2013;95:111–7.
KEY WORDS complications, valve in valve, transcatheter valve implantation
A PPE NDI X For supplemental videos and their legends, please see the online version of this article.
e189
VOL. 7, NO. 12, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 1936-8798/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jcin.2014.06.020
IMAGES IN INTERVENTION
An Unexpected Finding Stuck Leaflet After Transapical Mitral Valve-in-Valve Implantation Augusto D’Onofrio, MD, PHD,* Michele Gallo, MD,* Giuseppe Tarantini, MD, PHD,y Umberto Cucchini, MD, PHD,y Demetrio Pittarello, MD,z Gino Gerosa, MD*
T
ransapical mitral valve-in-valve (ViV) im-
II bioprosthesis (Medtronic, Minneapolis, Minnesota).
plantation was performed in an inoperable
The true internal diameter of the 29-mm Hancock II
patient with a dysfunctional 29-mm Hancock
valve is 24 mm (1), thus a 26-mm Sapien-XT (Edwards
F I G U R E 1 Fluoroscopic Image of Transapical Deployment of the 26-mm Edwards Sapien XT Bioprosthesis
(A) The 26-mm Edwards Sapien XT bioprosthesis is deployed into the stent of the 29-mm Hancock II. Post-deployment fluoroscopic image shows the final result (Online Video 1). (B) The “hour-glass” shape of the Sapien XT valve results from the discrepancy of size between the valves. Intraoperative transesophageal echocardiography shows normal leaflet motion in diastole (C) and in systole (D) with no residual mitral regurgitation.
From the *Division of Cardiac Surgery, University of Padova, Padova, Italy; yDivision of Cardiology, University of Padova, Padova, Italy; and the zDivision of Anesthesiology, University of Padova, Padova, Italy. Dr. D’Onofrio is a transapical aortic valve implantation proctor for Edwards Lifesciences. Prof. Gerosa is a transapical aortic valve implantation proctor for Edwards Lifesciences; and has received speaker’s fees from St. Jude Medical and HeartWire. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
e188
D’Onofrio et al.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 12, 2014 DECEMBER 2014:e187–9
Leaflet Immobility After Mitral Valve-in-Valve
F I G U R E 2 3D-TEE at 6 and 12 Months
(A and B) Three-dimensional transesophageal echocardiography (3D-TEE) 6 months after the procedure shows a stuck valve leaflet (Online Video 2). After 12 months at 3D-TEE, we observed a similar condition (C and D). (Red asterisk indicates the stuck valve leaflet).
Lifesciences, Irvine, California) valve was implanted
other
(Figures 1A and 1B, Online Video 1). The procedure
deployment and incomplete opening of the Sapien-
possible
mechanisms
include
noncoaxial
was uneventful with no residual mitral regurgitation
XT valve frame as a result of the size discrepancy.
(Figures 1C and 1D). Warfarin was administered for
In particular, in this case, a suboptimal deployment
permanent atrial fibrillation. Pre-discharge echocar-
of the transcatheter valve was observed: fluoroscopy
diography showed a well-functioning Sapien-XT
showed an “hour-glass” shape of the Sapien-XT valve
valve with normal motion of the 3 pericardial leaflets.
because of a too “atrial” final positioning (30% to 35%
At 6-months follow-up echocardiography, 1 of the 3
of the valve on the atrial side of the radiopaque
pericardial leaflets was stuck in the closed position,
marker) rather than a more correct “conical” shape
whereas the other 2 leaflets showed normal motion
(10% to 15% only of the valve on the atrial side) (1,2)
(Figures 2A and 2B, Online Video 2). The same finding
that may also help in preventing atrial migration of
was observed 12 months later (Figures 2C and 2D). The
the valve. Although transapical mitral ViV implanta-
patient is in excellent clinical condition; her New
tion is technically feasible (3,4), stuck valve leaflets
York Heart Association functional class is I at
is a potential complication that implanting physicians
follow-up, and mean transmitral gradient is only 5
should be aware of.
mm Hg. Therefore, we decided to closely monitor the patient with no indications for further invasive
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
treatment unless some changes in her clinical and/
Augusto D’Onofrio, Division of Cardiac Surgery,
or echocardiographic status should occur. Although
Department of Cardiac, Thoracic and Vascular Sci-
no images of valve thrombosis were found, this is
ences, Via Giustiniani 2, 35128 Padova, Italy. E-mail:
the most likely etiology of the stuck leaflet. However,
[email protected].
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 12, 2014 DECEMBER 2014:e187–9
D’Onofrio et al. Leaflet Immobility After Mitral Valve-in-Valve
REFERENCES 1. Bapat VN, Attia R, Thomas M. Effect of valve design on the stent internal diameter of a bioprosthetic valve: a concept of true internal diameter and its implications for the valve-in-valve procedure. J Am Coll Cardiol Intv 2014;7:115–27. 2. Bapat VN, Khaliel F, Ihlberg L. Delayed migration of a Sapien valve following a transcatheter mitral valve-in-valve implantation. Catheter Cardiovasc Interv 2014;83:E150–4.
3. Seiffert M, Conradi L, Baldus S, et al. Transcatheter mitral valve-in-valve implantation in patients with degenerated bioprostheses. J Am Coll Cardiol Intv 2012;5:341–9. 4. Wilbring M, Alexiou K, Tugtekin SM, et al. Transapical transcatheter valve-in-valve implantation for deteriorated mitral valve bioprostheses. Ann Thorac Surg 2013;95:111–7.
KEY WORDS complications, valve in valve, transcatheter valve implantation
A PPE NDI X For supplemental videos and their legends, please see the online version of this article.
e189
