Transapical Mitral Valve-In-Valve Implantation for Patients in Cardiogenic Shock Berhane Worku, MD, Andreas R. de Biasi, MD, Iosif Gulkarov, MD, Shing-Chiu Wong, MD, and Arash Salemi, MD Weill Cornell Medical Center/New York Presbyterian Hospital, New York; and New York Methodist Hospital, Brooklyn, New York
Transcatheter aortic valve implantation has demonstrated excellent results in high risk and inoperable patients, and been extended to valve-in-valve implantation for those with prosthetic aortic and, more recently, mitral valve failure. Despite its use in high risk and inoperable patients, active cardiogenic shock has historically been considered a contraindication. We describe 2 patients in acute cardiogenic shock from prosthetic mitral valve failure treated with transcatheter mitral valve-in-valve implantation. Transcatheter mitral valve therapies should be considered in patients in cardiogenic shock from prosthetic mitral valve failure, although, larger studies are needed to make any strong recommendation. (Ann Thorac Surg 2015;99:e103–5) Ó 2015 by The Society of Thoracic Surgeons
A
s excellent outcomes are realized in transcatheter aortic valve replacement, this technology has successfully been expanded to valve-in-valve therapy for patients considered high risk for reoperative valve replacement. Although transcatheter valve therapies are primarily utilized in high risk or inoperable patients, active shock has been considered a contraindication. We report the first 2 cases to our knowledge, as determined by an extensive literature search, of mitral valve-in-valve replacement (MVIVR) for patients in cardiogenic shock from prosthetic mitral regurgitation and stenosis.
Case Reports Patient 1 The first patient is an 80-year-old female with a history of hypertension, atrial fibrillation on warfarin, rheumatic fever, endocarditis, mitral valve replacement 2, in 1976 and last in 1996 (27 mm bioprosthetic valve), and tricuspid valve replacement in 2004 (33 m bioprosthetic valve) who presented with 1 week of worsening dyspnea and orthopnea. Transesophageal echocardiogram (TEE) revealed a normal ejection fraction, a well-seated mitral bioprosthesis with severe transvalvular mitral regurgitation, severe pulmonary hypertension, and left and right atrial thrombus. Cardiac catheterization demonstrated normal coronaries.
Right heart catheterization was deferred due to right atrial thrombus. Over the next 48 hours, despite diuresis she became more dyspneic, hypotensive, and hypoxic requiring intubation and vasoactive pharmacologic support. Creatinine rose to 2.03 mg/dL (baseline 1.47 mg/dL). Vasopressor and inotropic support included norepinephrine 9 mg/minute, vasopressin 2.4 U/hour, and milrinone 0.25 mg $ kg 1 $ min 1. Her predicted Society of Thoracic Surgeons (STS) mortality risk score was 42%. The decision was made to proceed with high-risk transapical MVIVR. The patient was brought to the hybrid operating room. Under fluoroscopic and TEE guidance, through a left anterolateral thoracotomy, the left ventricular apex was accessed and a sheath placed. During a period of rapid ventricular pacing, a 26-mm SAPIEN (Edwards Lifesciences, Irvine, CA) valve was placed across the prior bioprosthetic mitral valve. Fluoroscopic images during valve deployment are demonstrated in Figure 1. Postoperative TEE revealed a well-functioning prosthesis with trace paravalvular regurgitation. Postoperatively, the patient required a short course of hemodialysis, implantable cardio defibrillator placement, and tracheostomy, and was discharged to a rehabilitation facility on postoperative day 54. Follow-up transthoracic echocardiogram (TTE) at 6 weeks postoperatively demonstrated a well-seated mitral prosthesis with no paravalvular regurgitation. At 3 months follow-up the patient was alive and well although still somewhat debilitated. The patient ultimately expired 4 months postoperatively due to unrelated causes.
Patient 2 The second patient is an 85-year-old male with a history of hypertension, diabetes, sleep apnea, renal insufficiency, atrial fibrillation, biventricular internal cardio defibrillator, deep vein thrombosis, coronary stenting, coronary artery bypass grafting, and mitral valve replacement (27-mm bioprosthesis) in 2000, and vein graft stenting and transapical aortic valve implantation in 2013, who presented to an outside hospital with shortness of breath and orthopnea. He was transferred to our institution after an echocardiogram demonstrated significant prosthetic mitral stenosis and regurgitation. Diuresis was instituted. TTE demonstrated an ejection fraction of 0.61 and a well-seated mitral bioprosthesis with thickened, calcified cusps, 1 of which was immobile, another which was flail, and a third with reduced excursion, associated with severe mitral regurgitation and mild to moderate mitral stenosis with a mean transmitral gradient of 13 mm Hg. There was mild paravalvular prosthetic aortic regurgitation. Right heart catheterization demonstrated pulmonary
Accepted for publication Jan 16, 2015. Address correspondence to Dr Worku, New York Methodist Hospital, Department of Cardiothoracic Surgery, 506 6th St, Brooklyn, NY, 11215; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Drs Wong and Salemi disclose financial relationships with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.046
e104
CASE REPORT WORKU ET AL MITRAL VALVE-IN-VALVE IN SHOCK
Ann Thorac Surg 2015;99:e103–5
aortic valve replacement and lysed, and the left ventricular apex was accessed. Under fluoroscopic and TEE guidance, a sheath was placed. During a period of rapid ventricular pacing, a 26-mm SAPIEN (Edwards Lifesciences) valve was deployed across the prior bioprosthetic mitral valve (Fig 2). Pulmonary artery pressures decreased from 100 to 55 mm Hg. Postoperative TEE revealed a well-functioning prosthesis with trace paravalvular regurgitation and a reduction in the transmitral gradient from 12 to 4 mm Hg. The patient did well postoperatively, with weaning from all pharmacologic support. The IABP counterpulsation was discontinued on postoperative day 1 and the patient extubated postoperative day 4. Renal function recovered with cessation of hemodialysis and the patient was discharged to a rehabilitation facility on postoperative day 19. At 6 months postoperatively he was ambulating short distances and upstairs at home. Follow-up TTE at that time demonstrated a well-seated mitral prosthesis with mild paravalvular regurgitation.
Comment
Fig 1. Fluoroscopic images demonstrating mitral valve-in-valve deployment. (A) Valve positioning; (B) Balloon inflation for valve deployment; (C) Post deployment.
artery pressures of 79/30 mm Hg. Creatinine rose to 3.65 mg/dL (baseline 1.37 mg/dL) with persistent dyspnea and the patient was transferred to the intensive care unit for inotrope assisted diuresis and eventually continuous venovenous hemodialysis. Reoperative transapical MVIVR was planned. The day prior to the scheduled procedure, the patient developed worsening hypotension with mean arterial pressures of 40 to 50 mm Hg and pulmonary systolic pressures of 90 mm Hg, requiring intubation and escalation of hemodynamic support, including norepinephrine 32 mg/minute, phenylephrine 360 mg/minute, vasopressin 4 U/hour, dobutamine 4 mg $ kg 1 $ min 1, dopamine 20 mg $ kg 1 $ min 1, epinephrine 32 mg/ minute, intraaortic balloon pump (IABP) counterpulsation, and inhaled nitric oxide at 20 ppm. His predicted STS mortality risk score was 87%. The decision was made to proceed with high-risk transapical MVIVR. The patient was brought to the hybrid operating room. Through a left anterolateral thoracotomy, dense adhesions were encountered as a result of prior transapical
Transcatheter aortic valve-in-valve implantation has been demonstrated safe and effective, and more recently transcatheter mitral valve-in-valve, valve-in-ring, and valve-innative-ring implantations have been described with good outcomes as well [1–4]. Transfemoral, transatrial, and transapical approaches have all been described. The transapical approach is most favored due to shorter, more direct, and coaxial access to the mitral valve [2]. Contrast is generally not needed as the radiopaque sewing ring provides an excellent landmark for valve deployment. Various case series have demonstrated significant improvement in mean gradients and heart failure in high risk and inoperable patients in an elective setting [2, 4]. This is the first report, as determined by an extensive literature search, describing the use of MVIVR in hemodynamically unstable, shock patients. Transcatheter valve implantation in the aortic position has been described in patients in cardiogenic shock with 30-day mortality rates of 19% [5]. While significantly higher than standard transcatheter valve implantation mortality rates, this figure is still substantially better than the expected mortality without intervention, and supports the concept of transcatheter valve therapies for patients in shock from bioprosthetic valve failure in other positions. Both of our patients were in shock secondary to rapidly progressive, decompensated acute on chronic mitral regurgitation with signs of multiorgan failure including renal, respiratory, and cardiac failure, requiring intubation, inotropic and vasopressor support, and IABP counterpulsation and hemodialysis in 1. Both patients had prior heart surgery through sternotomy, and 1 had also undergone prior transapical aortic valve implantation making the transapical route a reoperative one as well. Despite this, both patients had uncomplicated operative courses and survived to discharge despite a preoperative status that would have likely been fatal in the setting of standard surgical intervention or medical management alone.
Ann Thorac Surg 2015;99:e103–5
CASE REPORT WORKU ET AL MITRAL VALVE-IN-VALVE IN SHOCK
e105
subsequently developed significant hemodynamic instability and progressive multiorgan failure that would have excluded them even from transcatheter therapies under standard guidelines. Despite this, both patients had unremarkable operative courses and survived to discharge. Transcatheter MVIVR should be considered as a potential option in cardiogenic shock patients. Larger studies are warranted before a strong recommendation can be made across all cases.
References
Fig 2. Fluoroscopic image demonstrating mitral valve-in-valve positioning.
In conclusion, we describe the use of MVIVR technology for patients in cardiogenic shock from bioprosthetic mitral regurgitation and stenosis. Both patients were deemed inoperable at baseline due to a profile of medical and surgical comorbidities and
1. Raval J, Nagaraja V, Eslick GD, Denniss AR. Transcatheter valve-in-valve implantation: a systematic review of the literature. Heart Lung Circ 2014;23:1020–8. 2. Cheung A, Webb JG, Barbanti M, et al. 5-year experience with transcatheter transapical mitral valve-in-valve implantation for bioprosthetic valve dysfunction. J Am Coll Cardiol 2013;61: 1759–66. 3. Wilbring M, Alexiou K, Tugtekin SM, et al. Pushing the limits-further evolutions of transcatheter valve procedures in the mitral position, including valve-in-valve, valve-in-ring, and valve-in-native-ring. J Thorac Cardiovasc Surg 2014;147: 210–9. 4. Seiffert M, Conradi L, Baldus S, et al. Transcatheter mitral valve-in-valve implantation in patients with degenerated bioprostheses. JACC Cardiovasc Interv 2012;5:341–9. 5. D’Ancona G, Pasic M, Buz S, et al. Transapical transcatheter aortic valve replacement in patients with cardiogenic shock. Interact Cardiovasc Thorac Surg 2012;14:426–30.
Transcatheter aortic valve implantation has demonstrated excellent results in high risk and inoperable patients, and been extended to valve-in-valve implantation for those with prosthetic aortic and, more recently, mitral valve failure. Despite its use in high risk and inoperable patients, active cardiogenic shock has historically been considered a contraindication. We describe 2 patients in acute cardiogenic shock from prosthetic mitral valve failure treated with transcatheter mitral valve-in-valve implantation. Transcatheter mitral valve therapies should be considered in patients in cardiogenic shock from prosthetic mitral valve failure, although, larger studies are needed to make any strong recommendation. (Ann Thorac Surg 2015;99:e103–5) Ó 2015 by The Society of Thoracic Surgeons
A
s excellent outcomes are realized in transcatheter aortic valve replacement, this technology has successfully been expanded to valve-in-valve therapy for patients considered high risk for reoperative valve replacement. Although transcatheter valve therapies are primarily utilized in high risk or inoperable patients, active shock has been considered a contraindication. We report the first 2 cases to our knowledge, as determined by an extensive literature search, of mitral valve-in-valve replacement (MVIVR) for patients in cardiogenic shock from prosthetic mitral regurgitation and stenosis.
Case Reports Patient 1 The first patient is an 80-year-old female with a history of hypertension, atrial fibrillation on warfarin, rheumatic fever, endocarditis, mitral valve replacement 2, in 1976 and last in 1996 (27 mm bioprosthetic valve), and tricuspid valve replacement in 2004 (33 m bioprosthetic valve) who presented with 1 week of worsening dyspnea and orthopnea. Transesophageal echocardiogram (TEE) revealed a normal ejection fraction, a well-seated mitral bioprosthesis with severe transvalvular mitral regurgitation, severe pulmonary hypertension, and left and right atrial thrombus. Cardiac catheterization demonstrated normal coronaries.
Right heart catheterization was deferred due to right atrial thrombus. Over the next 48 hours, despite diuresis she became more dyspneic, hypotensive, and hypoxic requiring intubation and vasoactive pharmacologic support. Creatinine rose to 2.03 mg/dL (baseline 1.47 mg/dL). Vasopressor and inotropic support included norepinephrine 9 mg/minute, vasopressin 2.4 U/hour, and milrinone 0.25 mg $ kg 1 $ min 1. Her predicted Society of Thoracic Surgeons (STS) mortality risk score was 42%. The decision was made to proceed with high-risk transapical MVIVR. The patient was brought to the hybrid operating room. Under fluoroscopic and TEE guidance, through a left anterolateral thoracotomy, the left ventricular apex was accessed and a sheath placed. During a period of rapid ventricular pacing, a 26-mm SAPIEN (Edwards Lifesciences, Irvine, CA) valve was placed across the prior bioprosthetic mitral valve. Fluoroscopic images during valve deployment are demonstrated in Figure 1. Postoperative TEE revealed a well-functioning prosthesis with trace paravalvular regurgitation. Postoperatively, the patient required a short course of hemodialysis, implantable cardio defibrillator placement, and tracheostomy, and was discharged to a rehabilitation facility on postoperative day 54. Follow-up transthoracic echocardiogram (TTE) at 6 weeks postoperatively demonstrated a well-seated mitral prosthesis with no paravalvular regurgitation. At 3 months follow-up the patient was alive and well although still somewhat debilitated. The patient ultimately expired 4 months postoperatively due to unrelated causes.
Patient 2 The second patient is an 85-year-old male with a history of hypertension, diabetes, sleep apnea, renal insufficiency, atrial fibrillation, biventricular internal cardio defibrillator, deep vein thrombosis, coronary stenting, coronary artery bypass grafting, and mitral valve replacement (27-mm bioprosthesis) in 2000, and vein graft stenting and transapical aortic valve implantation in 2013, who presented to an outside hospital with shortness of breath and orthopnea. He was transferred to our institution after an echocardiogram demonstrated significant prosthetic mitral stenosis and regurgitation. Diuresis was instituted. TTE demonstrated an ejection fraction of 0.61 and a well-seated mitral bioprosthesis with thickened, calcified cusps, 1 of which was immobile, another which was flail, and a third with reduced excursion, associated with severe mitral regurgitation and mild to moderate mitral stenosis with a mean transmitral gradient of 13 mm Hg. There was mild paravalvular prosthetic aortic regurgitation. Right heart catheterization demonstrated pulmonary
Accepted for publication Jan 16, 2015. Address correspondence to Dr Worku, New York Methodist Hospital, Department of Cardiothoracic Surgery, 506 6th St, Brooklyn, NY, 11215; e-mail: [email protected].
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
Drs Wong and Salemi disclose financial relationships with Edwards Lifesciences.
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.046
e104
CASE REPORT WORKU ET AL MITRAL VALVE-IN-VALVE IN SHOCK
Ann Thorac Surg 2015;99:e103–5
aortic valve replacement and lysed, and the left ventricular apex was accessed. Under fluoroscopic and TEE guidance, a sheath was placed. During a period of rapid ventricular pacing, a 26-mm SAPIEN (Edwards Lifesciences) valve was deployed across the prior bioprosthetic mitral valve (Fig 2). Pulmonary artery pressures decreased from 100 to 55 mm Hg. Postoperative TEE revealed a well-functioning prosthesis with trace paravalvular regurgitation and a reduction in the transmitral gradient from 12 to 4 mm Hg. The patient did well postoperatively, with weaning from all pharmacologic support. The IABP counterpulsation was discontinued on postoperative day 1 and the patient extubated postoperative day 4. Renal function recovered with cessation of hemodialysis and the patient was discharged to a rehabilitation facility on postoperative day 19. At 6 months postoperatively he was ambulating short distances and upstairs at home. Follow-up TTE at that time demonstrated a well-seated mitral prosthesis with mild paravalvular regurgitation.
Comment
Fig 1. Fluoroscopic images demonstrating mitral valve-in-valve deployment. (A) Valve positioning; (B) Balloon inflation for valve deployment; (C) Post deployment.
artery pressures of 79/30 mm Hg. Creatinine rose to 3.65 mg/dL (baseline 1.37 mg/dL) with persistent dyspnea and the patient was transferred to the intensive care unit for inotrope assisted diuresis and eventually continuous venovenous hemodialysis. Reoperative transapical MVIVR was planned. The day prior to the scheduled procedure, the patient developed worsening hypotension with mean arterial pressures of 40 to 50 mm Hg and pulmonary systolic pressures of 90 mm Hg, requiring intubation and escalation of hemodynamic support, including norepinephrine 32 mg/minute, phenylephrine 360 mg/minute, vasopressin 4 U/hour, dobutamine 4 mg $ kg 1 $ min 1, dopamine 20 mg $ kg 1 $ min 1, epinephrine 32 mg/ minute, intraaortic balloon pump (IABP) counterpulsation, and inhaled nitric oxide at 20 ppm. His predicted STS mortality risk score was 87%. The decision was made to proceed with high-risk transapical MVIVR. The patient was brought to the hybrid operating room. Through a left anterolateral thoracotomy, dense adhesions were encountered as a result of prior transapical
Transcatheter aortic valve-in-valve implantation has been demonstrated safe and effective, and more recently transcatheter mitral valve-in-valve, valve-in-ring, and valve-innative-ring implantations have been described with good outcomes as well [1–4]. Transfemoral, transatrial, and transapical approaches have all been described. The transapical approach is most favored due to shorter, more direct, and coaxial access to the mitral valve [2]. Contrast is generally not needed as the radiopaque sewing ring provides an excellent landmark for valve deployment. Various case series have demonstrated significant improvement in mean gradients and heart failure in high risk and inoperable patients in an elective setting [2, 4]. This is the first report, as determined by an extensive literature search, describing the use of MVIVR in hemodynamically unstable, shock patients. Transcatheter valve implantation in the aortic position has been described in patients in cardiogenic shock with 30-day mortality rates of 19% [5]. While significantly higher than standard transcatheter valve implantation mortality rates, this figure is still substantially better than the expected mortality without intervention, and supports the concept of transcatheter valve therapies for patients in shock from bioprosthetic valve failure in other positions. Both of our patients were in shock secondary to rapidly progressive, decompensated acute on chronic mitral regurgitation with signs of multiorgan failure including renal, respiratory, and cardiac failure, requiring intubation, inotropic and vasopressor support, and IABP counterpulsation and hemodialysis in 1. Both patients had prior heart surgery through sternotomy, and 1 had also undergone prior transapical aortic valve implantation making the transapical route a reoperative one as well. Despite this, both patients had uncomplicated operative courses and survived to discharge despite a preoperative status that would have likely been fatal in the setting of standard surgical intervention or medical management alone.
Ann Thorac Surg 2015;99:e103–5
CASE REPORT WORKU ET AL MITRAL VALVE-IN-VALVE IN SHOCK
e105
subsequently developed significant hemodynamic instability and progressive multiorgan failure that would have excluded them even from transcatheter therapies under standard guidelines. Despite this, both patients had unremarkable operative courses and survived to discharge. Transcatheter MVIVR should be considered as a potential option in cardiogenic shock patients. Larger studies are warranted before a strong recommendation can be made across all cases.
References
Fig 2. Fluoroscopic image demonstrating mitral valve-in-valve positioning.
In conclusion, we describe the use of MVIVR technology for patients in cardiogenic shock from bioprosthetic mitral regurgitation and stenosis. Both patients were deemed inoperable at baseline due to a profile of medical and surgical comorbidities and
1. Raval J, Nagaraja V, Eslick GD, Denniss AR. Transcatheter valve-in-valve implantation: a systematic review of the literature. Heart Lung Circ 2014;23:1020–8. 2. Cheung A, Webb JG, Barbanti M, et al. 5-year experience with transcatheter transapical mitral valve-in-valve implantation for bioprosthetic valve dysfunction. J Am Coll Cardiol 2013;61: 1759–66. 3. Wilbring M, Alexiou K, Tugtekin SM, et al. Pushing the limits-further evolutions of transcatheter valve procedures in the mitral position, including valve-in-valve, valve-in-ring, and valve-in-native-ring. J Thorac Cardiovasc Surg 2014;147: 210–9. 4. Seiffert M, Conradi L, Baldus S, et al. Transcatheter mitral valve-in-valve implantation in patients with degenerated bioprostheses. JACC Cardiovasc Interv 2012;5:341–9. 5. D’Ancona G, Pasic M, Buz S, et al. Transapical transcatheter aortic valve replacement in patients with cardiogenic shock. Interact Cardiovasc Thorac Surg 2012;14:426–30.
