Catheterization and Cardiovascular Interventions 87:1342–1346 (2016)
Emergent Transcatheter Mitral Valve-in-Valve Implantation in a Patient With Cardiogenic Shock Secondary to a Failed Mitral Bioprosthesis Oluseun Alli,1* MD, Oscar Booker,1 MD, and James Davies,2 MD 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. C 2015 Wiley Periodicals, Inc. V
Key words: mitral valve disease; structural heart disease intervention; mitral valve disease; percutaneous intervention
INTRODUCTION
CASE DESCRIPTION
Transcatheter valve-in-valve (VIV) implantation for failing bioprosthesis has emerged as a suitable and viable alternative to redo-valve replacement surgery in patients with failing bioprosthetic valves [1,2]. Though the transcatheter VIV procedure can be performed in almost all bioprosthetic valves in any position, it is most commonly performed in failing aortic bioprosthesis. There have been several reports of transcatheter VIV in the mitral position usually in high-risk but relatively stable patients. We hereby report the first case of a successful transcatheter mitral VIV implantation in an emergency situation in a patient with severe mitral bioprosthesis stenosis and cardiogenic shock.
A 60-year-old man with history of mitral valve replacement with a 29 mm Carpentier-Edwards’s prosthesis 4 years prior was transferred from an outside hospital to our center on account of progressive dyspnea with NYHA Class IV heart failure symptoms and severe stenosis of the existing mitral bioprosthesis. Shortly after arrival in our center, he deteriorated with worsening respiratory failure and production of pink frothy sputum (chest X-ray revealed extensive bilateral pulmonary infiltrates suggestive of severe pulmonary edema, Fig. 1A) and marked hypotension, he was emergently intubated and started on three vasopressors to maintain his blood pressure. He remained in cardiogenic shock with deterioration of his renal function and worsening liver function with coagulopathy requiring increasing vasopressor requirements to maintain his blood pressure, at this point he was deemed extreme risk for surgical redo-mitral valve replacement and transcatheter mitral VIV procedure was proposed. Due to his coagulopathy, the transapical access was not considered so an antegrade transseptal access was proposed. Pre-procedural transesophageal echocardiogram (TEE) revealed severe stenosis of the mitral bioprosthetic leaflets with a 30 mm Hg mean gradient across the prosthesis (Fig. 1B–D, Supporting Information Videos 1 and 2), similarly right heart catheterization revealed severe pulmonary hypertension (Fig. 1E) and direct left atrial (LA) pressure assessment revealed markedly elevated LA pressure with a mean LA
1
Division of Cardiology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 2 Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama Conflict of interest: Nothing to report. *Correspondence to: Oluseun Alli, MD, Assistant Professor of Medicine, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294. E-mail: [email protected] Received 10 February 2015; Revision accepted 8 May 2015 DOI: 10.1002/ccd.26040 Published online 27 May 2015 in Wiley Online Library (wileyonlinelibrary.com) C 2015 Wiley Periodicals, Inc. V
Emergent Transcatheter VIV Implantation for Failing Bioprosthesis
1343
Fig. 1. A: Chest X-ray revealing severe bilateral infiltrates. B, C: Severely stenotic mitral valve leaflets and reduced flow through the valve. D: Elevated transmitral valve gradient by continuous wave Doppler across the mitral bioprosthesis. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
pressure of 54 mm Hg (Fig. 1F). Access was via the right femoral vein, transseptal access was performed using standard techniques and the severely stenotic valve was crossed and a Lunderquist wire (Cook Medical) placed in the left ventricle (Fig. 2A). Thereafter the interatrial septum was dilated with a 10 3 20 mm balloon (Fig. 2B), valvuloplasty was performed with a 20 3 4 Z-Med II balloon (B Braun Medical Systems) (Charanjit Rihal Personal communication, 2014). The existing mitral bioprosthesis was a Carpentier Edwards perimount valve which has a stent internal diameter of 29 mm and a true internal diameter of 27 mm and the suggested transcatheter valve size for VIV implantation was a 29 mm Sapien based on recommendations from the VIV app. Therefore, a 29-mm Edwards Sapien XT (Edwards Lifesciences) valve was delivered across the mitral prosthesis and successfully deployed under rapid
ventricular pacing at 120 beats per minute (Fig. 2C and D, Supporting Information Video 3). We aimed to deploy the valve with about 30% of the new prosthesis deployed on the atrial side of the existing prosthesis leading to the Sapien being 10% higher on the atrial end of the fluoroscopic portion of the stent. There was trivial intraprosthetic valve regurgitation but there was mild to moderate periprosthetic insufficiency following transcatheter heart valve (THV) valve implantation, thus post dilation was performed after addition of 1 cc of contrast to the insufflator with reduction in periprosthetic insufficiency to trivial. Intra-procedural TEE revealed a well-seated VIV prosthesis with large orifice and a mean gradient of 3 mm Hg across the valve (Fig. 2E and F, Supporting Information Video 4). He did well post procedure, successfully extubated the following day, his pulmonary pressures continued
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
1344
Alli et al.
Fig. 2. A: Lunderquist wire across the bioprosthetic valve and positioned in the left ventricle. B: The inter-atrial septum is dilated with a 10 3 20 mm balloon to facilitate device crossing into the LA. C: Deployment of the 29 mm Sapien XT valve within the existing mitral bioprosthesis. D: Final position
of the Sapien XT valve within the existing mitral bioprosthesis. E: 3-D TEE images of the wide-open valve orifice. F: Postprocedure mitral valve gradient, mean gradient 3 mm Hg. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
to decline following the procedure and he was discharged home 5 days after the procedure. He was seen in clinic 4 weeks after discharge, at that visit he was in NYHA class I–II, he felt much better and his follow-up TTE revealed a well seated mitral valve bioprosthesis with a gradient of 5 mm Hg across the valve and no mitral regurgitation (Supporting Information Video 5).
aortic valve replacement for severe aortic stenosis in native valves, shorter durability of bioprosthetic valves, and the higher operative risk associated with redovalve operation with failed bioprosthetic valves. There are several reports documenting the VIV approach for bioprosthetic valves in the aortic, mitral, pulmonary, and tricuspid positions [1,2,4,5]. In majority of these cases the procedure is performed in high-risk patients with operative mortality >10% using the Society of Thoracic Surgeons (STS) risk score in an elective or semi-elective situation and majority have been performed in degenerative bioprosthesis in the aortic position. Similarly transcatheter VIV for degenerative cases is usually performed in an elective manner in high-risk patients and this can be accomplished using either the transapical or transseptal approach. Cullen et al. published a case series of 19 patients undergoing VIV for degenerated tricuspid and mitral bioprosthesis with significant improvement in
DISCUSSION
We report the first successful case of an emergency transcatheter mitral VIV using an antegrade transseptal approach. Fassa et al. recently reported a case of emergent transcatheter mitral VIV but this was complicated by valve migration and embolization leading to prolonged hospitalization and eventual patient demise [3]. Transcatheter VIV procedures are becoming increasingly performed due to the success of the transcatheter
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Emergent Transcatheter VIV Implantation for Failing Bioprosthesis
NYHA functional class and 0% 30-day mortality rate [6]. Adequate knowledge of bioprosthetic valve design is essential for operators involved in these cases; the most important issue is to adequately size the bioprosthesis for implantation of the new valve. The newly created VIV app has been useful in determining what valve size should be used in the commonly used bioprosthesis. Other options for sizing include the use of TEE or CT imaging. Transcatheter mitral VIV has been rarely performed in an emergent fashion but may be a therapeutic option in critical ill patients with severely degenerated mitral bioprosthesis and heart failure/cardiogenic shock. We suggest the use of the antegrade transseptal approach in these cases as it may be associated with less access site complications when compared to the transapical approach. Potential complications with this approach include access site bleeding, femoral vein/inferior vena cava perforation, iatrogenic atrial septal defect, valve embolization, and perforation of the left ventricle by the stiff wire. Rapid ventricular pacing is advocated for these cases as it helps maintain valve stability during deployment and potentially help mitigate THV migration, rates varying from 140 to 200 beats per minute have been used, we opted to use rates of 120 beats per minute to avoid precipitating significant hypotension as the patient was in shock. We opted to perform balloon valvuloplasty of the existing bioprosthesis as we felt that the bioprosthetic stenosis was quite critical and may prevent passage of the large valve delivery system without some predilation. The use of hemodynamic support devices is often contemplated in emergent cases; there have been reported cases of the use of extracorporeal membrane oxygenation (ECMO) for hemodynamic support [3] and the Impella or Tandem device may also be considered. Since the reason for shock is at the atrial level due to underfilling of the left ventricle devices that depend on adequate left ventricular filling (preload) such as the Impella device may not be effective. The ECMO or Tandem heart devices would appear to offer a more favorable hemodynamic support in this situation, as they do not rely on ventricular preload to function. In addition, the use of ECMO in this situation allows for oxygenation as most patients in this situation have significant pulmonary edema that may make adequate ventilation difficult to achieve. Bouleti et al. recently reported a case series of 17 patients that underwent antegrade transseptal transcatheter mitral VIV in severely degenerated mitral bioprosthesis and rings with 82% success rate and 18% complication rate [7]. In this series, 3 out of 17 patients underwent an emergent procedure, 2 out of 3
1345
patients undergoing this emergent VIV implantation did have a procedural complication—1 patient died and the other patient had THV migration compared with 14 patients undergoing elective VIV implantation who had no periprocedural complication. These results reflect the increased risk and complexity involved with emergent procedures. The challenges of an antegrade transseptal approach for transcatheter VIV are numerous; aside from the complications detailed earlier, there are also technical difficulties with this approach. These include difficulty with advancing the large Sapien delivery system across the interatrial septum (IAS), despite adequate balloon dilation of the IAS, a major technical difficulty is sometimes achieving a coaxial valve positioning and deployment that may lead to THV embolization. This can be overcome by careful positioning; slow valve deployment with adjustments during deployment and sometimes the use of left ventricular apical puncture with creation of an arteriovenous rail system can also ensure adequate positioning. The use of LV apical puncture technique may lead complications such as hemothorax (most common), coronary injury amongst others. Occasionally, the large valve delivery system may create an iatrogenic atrial septal defect, in most patients this creates a small left to right shunt but occasionally in some patients with severe pulmonary hypertension and severely elevated right heart pressures there may be significant right to left shunt. Our patient had a small residual iatrogenic atrial septal defect (ASD) with a small left to right shunt. In cases of significant shunting across the ASD, percutaneous closure with appropriate device(s) is recommended either at the same setting or at follow-up. Anticoagulant and antiplatelet therapies involve the use of procedural heparin and aspirin and postprocedure dual antiplatelet therapy with aspirin and clopidogrel is recommended. If they are on oral anticoagulants for other reasons such as atrial fibrillation then we recommend addition of low dose aspirin to the oral anticoagulant regimen.
CONCLUSION
In conclusion, antegrade transseptal transcatheter mitral VIV implantation can be performed successfully in an emergent situation in patients with cardiogenic shock and failing mitral bioprosthesis. REFERENCES 1. Webb JG, Wood JG, Ye DA, Gurvitch J, Masson R, RodesCabau JB, Osten J, Horlick M, Wendler E, Dumont O, Carere E, Wijesinghe RG, Nietlispach N, Johnson F, Thompson M,
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
1346
Alli et al.
Moss CR, Leipsic R, Munt J, Lichtenstein B, Cheung SVA. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation 2010;121:1848–1857. 2. Dvir D, Webb J, Brecker S, Bleiziffer S, Hildick-Smith D, Colombo A, Descoutures F, Hengstenberg C, Moat NE, Bekeredjian R, Napodano M, Testa L, Lefevre T, Guetta V, Nissen H, Hernandez JM, Roy D, Teles RC, Segev A, Dumonteil N, Fiorina C, Gotzmann M, Tchetche D, AbdelWahab M, De Marco F, Baumbach A, Laborde JC, Kornowski R. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: Results from the global valve-invalve registry. Circulation 2012;126:2335–2344. 3. Fassa AA, Himbert D, Brochet E, Alkhoder S, Al-Attar N, Brun PY, Wolff M, Nataf P, Vahanian A. Emergency transseptal transcatheter mitral valve-in-valve implantation. EuroIntervention 2013;9:636–642. 4. Descoutures F, Himbert D, Maisano F, Casselman F, de Weger A, Bodea O, Van der Kley F, Colombo A, Giannini C, Rein KA, De Bruyne B, Petronio AS, Dahle G, Alfieri O,
Vahanian A. Transcatheter valve-in-ring implantation after failure of surgical mitral repair. Eur J Cardiothorac Surg 2013;44:e8–e15. 5. Himbert D, Brochet E, Radu C, Iung B, Messika-Zeitoun D, Enguerrand D, Bougoin W, Nataf P, Vahanian A. Transseptal implantation of a transcatheter heart valve in a mitral annuloplasty ring to treat mitral repair failure. Circ Cardiovasc Interv 2011;4:396–398. 6. Cullen MW, Cabalka AK, Alli OO, Pislaru SV, Sorajja P, Nkomo VT, Malouf JF, Cetta F, Hagler DJ, Rihal CS. Transvenous, antegrade melody valve-in-valve implantation for bioprosthetic mitral and tricuspid valve dysfunction: A case series in children and adults. JACC Cardiovascular Interventions 2013;6: 598–605. 7. Bouleti C, Fassa AA, Himbert D, Brochet E, Ducrocq G, Nejjari M, Ghodbane W, Depoix JP, Nataf P, Vahanian A. Transfemoral implantation of transcatheter heart valves after deterioration of mitral bioprosthesis or previous ring annuloplasty. JACC Cardiovasc Interv 2015;8:83–91.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Emergent Transcatheter Mitral Valve-in-Valve Implantation in a Patient With Cardiogenic Shock Secondary to a Failed Mitral Bioprosthesis Oluseun Alli,1* MD, Oscar Booker,1 MD, and James Davies,2 MD 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. C 2015 Wiley Periodicals, Inc. V
Key words: mitral valve disease; structural heart disease intervention; mitral valve disease; percutaneous intervention
INTRODUCTION
CASE DESCRIPTION
Transcatheter valve-in-valve (VIV) implantation for failing bioprosthesis has emerged as a suitable and viable alternative to redo-valve replacement surgery in patients with failing bioprosthetic valves [1,2]. Though the transcatheter VIV procedure can be performed in almost all bioprosthetic valves in any position, it is most commonly performed in failing aortic bioprosthesis. There have been several reports of transcatheter VIV in the mitral position usually in high-risk but relatively stable patients. We hereby report the first case of a successful transcatheter mitral VIV implantation in an emergency situation in a patient with severe mitral bioprosthesis stenosis and cardiogenic shock.
A 60-year-old man with history of mitral valve replacement with a 29 mm Carpentier-Edwards’s prosthesis 4 years prior was transferred from an outside hospital to our center on account of progressive dyspnea with NYHA Class IV heart failure symptoms and severe stenosis of the existing mitral bioprosthesis. Shortly after arrival in our center, he deteriorated with worsening respiratory failure and production of pink frothy sputum (chest X-ray revealed extensive bilateral pulmonary infiltrates suggestive of severe pulmonary edema, Fig. 1A) and marked hypotension, he was emergently intubated and started on three vasopressors to maintain his blood pressure. He remained in cardiogenic shock with deterioration of his renal function and worsening liver function with coagulopathy requiring increasing vasopressor requirements to maintain his blood pressure, at this point he was deemed extreme risk for surgical redo-mitral valve replacement and transcatheter mitral VIV procedure was proposed. Due to his coagulopathy, the transapical access was not considered so an antegrade transseptal access was proposed. Pre-procedural transesophageal echocardiogram (TEE) revealed severe stenosis of the mitral bioprosthetic leaflets with a 30 mm Hg mean gradient across the prosthesis (Fig. 1B–D, Supporting Information Videos 1 and 2), similarly right heart catheterization revealed severe pulmonary hypertension (Fig. 1E) and direct left atrial (LA) pressure assessment revealed markedly elevated LA pressure with a mean LA
1
Division of Cardiology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama 2 Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama Conflict of interest: Nothing to report. *Correspondence to: Oluseun Alli, MD, Assistant Professor of Medicine, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294. E-mail: [email protected] Received 10 February 2015; Revision accepted 8 May 2015 DOI: 10.1002/ccd.26040 Published online 27 May 2015 in Wiley Online Library (wileyonlinelibrary.com) C 2015 Wiley Periodicals, Inc. V
Emergent Transcatheter VIV Implantation for Failing Bioprosthesis
1343
Fig. 1. A: Chest X-ray revealing severe bilateral infiltrates. B, C: Severely stenotic mitral valve leaflets and reduced flow through the valve. D: Elevated transmitral valve gradient by continuous wave Doppler across the mitral bioprosthesis. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
pressure of 54 mm Hg (Fig. 1F). Access was via the right femoral vein, transseptal access was performed using standard techniques and the severely stenotic valve was crossed and a Lunderquist wire (Cook Medical) placed in the left ventricle (Fig. 2A). Thereafter the interatrial septum was dilated with a 10 3 20 mm balloon (Fig. 2B), valvuloplasty was performed with a 20 3 4 Z-Med II balloon (B Braun Medical Systems) (Charanjit Rihal Personal communication, 2014). The existing mitral bioprosthesis was a Carpentier Edwards perimount valve which has a stent internal diameter of 29 mm and a true internal diameter of 27 mm and the suggested transcatheter valve size for VIV implantation was a 29 mm Sapien based on recommendations from the VIV app. Therefore, a 29-mm Edwards Sapien XT (Edwards Lifesciences) valve was delivered across the mitral prosthesis and successfully deployed under rapid
ventricular pacing at 120 beats per minute (Fig. 2C and D, Supporting Information Video 3). We aimed to deploy the valve with about 30% of the new prosthesis deployed on the atrial side of the existing prosthesis leading to the Sapien being 10% higher on the atrial end of the fluoroscopic portion of the stent. There was trivial intraprosthetic valve regurgitation but there was mild to moderate periprosthetic insufficiency following transcatheter heart valve (THV) valve implantation, thus post dilation was performed after addition of 1 cc of contrast to the insufflator with reduction in periprosthetic insufficiency to trivial. Intra-procedural TEE revealed a well-seated VIV prosthesis with large orifice and a mean gradient of 3 mm Hg across the valve (Fig. 2E and F, Supporting Information Video 4). He did well post procedure, successfully extubated the following day, his pulmonary pressures continued
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
1344
Alli et al.
Fig. 2. A: Lunderquist wire across the bioprosthetic valve and positioned in the left ventricle. B: The inter-atrial septum is dilated with a 10 3 20 mm balloon to facilitate device crossing into the LA. C: Deployment of the 29 mm Sapien XT valve within the existing mitral bioprosthesis. D: Final position
of the Sapien XT valve within the existing mitral bioprosthesis. E: 3-D TEE images of the wide-open valve orifice. F: Postprocedure mitral valve gradient, mean gradient 3 mm Hg. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
to decline following the procedure and he was discharged home 5 days after the procedure. He was seen in clinic 4 weeks after discharge, at that visit he was in NYHA class I–II, he felt much better and his follow-up TTE revealed a well seated mitral valve bioprosthesis with a gradient of 5 mm Hg across the valve and no mitral regurgitation (Supporting Information Video 5).
aortic valve replacement for severe aortic stenosis in native valves, shorter durability of bioprosthetic valves, and the higher operative risk associated with redovalve operation with failed bioprosthetic valves. There are several reports documenting the VIV approach for bioprosthetic valves in the aortic, mitral, pulmonary, and tricuspid positions [1,2,4,5]. In majority of these cases the procedure is performed in high-risk patients with operative mortality >10% using the Society of Thoracic Surgeons (STS) risk score in an elective or semi-elective situation and majority have been performed in degenerative bioprosthesis in the aortic position. Similarly transcatheter VIV for degenerative cases is usually performed in an elective manner in high-risk patients and this can be accomplished using either the transapical or transseptal approach. Cullen et al. published a case series of 19 patients undergoing VIV for degenerated tricuspid and mitral bioprosthesis with significant improvement in
DISCUSSION
We report the first successful case of an emergency transcatheter mitral VIV using an antegrade transseptal approach. Fassa et al. recently reported a case of emergent transcatheter mitral VIV but this was complicated by valve migration and embolization leading to prolonged hospitalization and eventual patient demise [3]. Transcatheter VIV procedures are becoming increasingly performed due to the success of the transcatheter
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
Emergent Transcatheter VIV Implantation for Failing Bioprosthesis
NYHA functional class and 0% 30-day mortality rate [6]. Adequate knowledge of bioprosthetic valve design is essential for operators involved in these cases; the most important issue is to adequately size the bioprosthesis for implantation of the new valve. The newly created VIV app has been useful in determining what valve size should be used in the commonly used bioprosthesis. Other options for sizing include the use of TEE or CT imaging. Transcatheter mitral VIV has been rarely performed in an emergent fashion but may be a therapeutic option in critical ill patients with severely degenerated mitral bioprosthesis and heart failure/cardiogenic shock. We suggest the use of the antegrade transseptal approach in these cases as it may be associated with less access site complications when compared to the transapical approach. Potential complications with this approach include access site bleeding, femoral vein/inferior vena cava perforation, iatrogenic atrial septal defect, valve embolization, and perforation of the left ventricle by the stiff wire. Rapid ventricular pacing is advocated for these cases as it helps maintain valve stability during deployment and potentially help mitigate THV migration, rates varying from 140 to 200 beats per minute have been used, we opted to use rates of 120 beats per minute to avoid precipitating significant hypotension as the patient was in shock. We opted to perform balloon valvuloplasty of the existing bioprosthesis as we felt that the bioprosthetic stenosis was quite critical and may prevent passage of the large valve delivery system without some predilation. The use of hemodynamic support devices is often contemplated in emergent cases; there have been reported cases of the use of extracorporeal membrane oxygenation (ECMO) for hemodynamic support [3] and the Impella or Tandem device may also be considered. Since the reason for shock is at the atrial level due to underfilling of the left ventricle devices that depend on adequate left ventricular filling (preload) such as the Impella device may not be effective. The ECMO or Tandem heart devices would appear to offer a more favorable hemodynamic support in this situation, as they do not rely on ventricular preload to function. In addition, the use of ECMO in this situation allows for oxygenation as most patients in this situation have significant pulmonary edema that may make adequate ventilation difficult to achieve. Bouleti et al. recently reported a case series of 17 patients that underwent antegrade transseptal transcatheter mitral VIV in severely degenerated mitral bioprosthesis and rings with 82% success rate and 18% complication rate [7]. In this series, 3 out of 17 patients underwent an emergent procedure, 2 out of 3
1345
patients undergoing this emergent VIV implantation did have a procedural complication—1 patient died and the other patient had THV migration compared with 14 patients undergoing elective VIV implantation who had no periprocedural complication. These results reflect the increased risk and complexity involved with emergent procedures. The challenges of an antegrade transseptal approach for transcatheter VIV are numerous; aside from the complications detailed earlier, there are also technical difficulties with this approach. These include difficulty with advancing the large Sapien delivery system across the interatrial septum (IAS), despite adequate balloon dilation of the IAS, a major technical difficulty is sometimes achieving a coaxial valve positioning and deployment that may lead to THV embolization. This can be overcome by careful positioning; slow valve deployment with adjustments during deployment and sometimes the use of left ventricular apical puncture with creation of an arteriovenous rail system can also ensure adequate positioning. The use of LV apical puncture technique may lead complications such as hemothorax (most common), coronary injury amongst others. Occasionally, the large valve delivery system may create an iatrogenic atrial septal defect, in most patients this creates a small left to right shunt but occasionally in some patients with severe pulmonary hypertension and severely elevated right heart pressures there may be significant right to left shunt. Our patient had a small residual iatrogenic atrial septal defect (ASD) with a small left to right shunt. In cases of significant shunting across the ASD, percutaneous closure with appropriate device(s) is recommended either at the same setting or at follow-up. Anticoagulant and antiplatelet therapies involve the use of procedural heparin and aspirin and postprocedure dual antiplatelet therapy with aspirin and clopidogrel is recommended. If they are on oral anticoagulants for other reasons such as atrial fibrillation then we recommend addition of low dose aspirin to the oral anticoagulant regimen.
CONCLUSION
In conclusion, antegrade transseptal transcatheter mitral VIV implantation can be performed successfully in an emergent situation in patients with cardiogenic shock and failing mitral bioprosthesis. REFERENCES 1. Webb JG, Wood JG, Ye DA, Gurvitch J, Masson R, RodesCabau JB, Osten J, Horlick M, Wendler E, Dumont O, Carere E, Wijesinghe RG, Nietlispach N, Johnson F, Thompson M,
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
1346
Alli et al.
Moss CR, Leipsic R, Munt J, Lichtenstein B, Cheung SVA. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation 2010;121:1848–1857. 2. Dvir D, Webb J, Brecker S, Bleiziffer S, Hildick-Smith D, Colombo A, Descoutures F, Hengstenberg C, Moat NE, Bekeredjian R, Napodano M, Testa L, Lefevre T, Guetta V, Nissen H, Hernandez JM, Roy D, Teles RC, Segev A, Dumonteil N, Fiorina C, Gotzmann M, Tchetche D, AbdelWahab M, De Marco F, Baumbach A, Laborde JC, Kornowski R. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: Results from the global valve-invalve registry. Circulation 2012;126:2335–2344. 3. Fassa AA, Himbert D, Brochet E, Alkhoder S, Al-Attar N, Brun PY, Wolff M, Nataf P, Vahanian A. Emergency transseptal transcatheter mitral valve-in-valve implantation. EuroIntervention 2013;9:636–642. 4. Descoutures F, Himbert D, Maisano F, Casselman F, de Weger A, Bodea O, Van der Kley F, Colombo A, Giannini C, Rein KA, De Bruyne B, Petronio AS, Dahle G, Alfieri O,
Vahanian A. Transcatheter valve-in-ring implantation after failure of surgical mitral repair. Eur J Cardiothorac Surg 2013;44:e8–e15. 5. Himbert D, Brochet E, Radu C, Iung B, Messika-Zeitoun D, Enguerrand D, Bougoin W, Nataf P, Vahanian A. Transseptal implantation of a transcatheter heart valve in a mitral annuloplasty ring to treat mitral repair failure. Circ Cardiovasc Interv 2011;4:396–398. 6. Cullen MW, Cabalka AK, Alli OO, Pislaru SV, Sorajja P, Nkomo VT, Malouf JF, Cetta F, Hagler DJ, Rihal CS. Transvenous, antegrade melody valve-in-valve implantation for bioprosthetic mitral and tricuspid valve dysfunction: A case series in children and adults. JACC Cardiovascular Interventions 2013;6: 598–605. 7. Bouleti C, Fassa AA, Himbert D, Brochet E, Ducrocq G, Nejjari M, Ghodbane W, Depoix JP, Nataf P, Vahanian A. Transfemoral implantation of transcatheter heart valves after deterioration of mitral bioprosthesis or previous ring annuloplasty. JACC Cardiovasc Interv 2015;8:83–91.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
