Excerpt

An 89-year-old woman with previous bioprosthetic mitral valve replacement had recent multiple hospital admissions for decompensated heart failure. Patient was found to have severe aortic stenosis and structural deterioration (i.e., severe regurgitation) of the previously implanted mitral bioprosthesis. Due to high surgical risk (STS score 23), patient was initially considered for transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve-in-valve. Computed tomography procedural planning revealed protruding bioprosthetic mitral valve struts into the left ventricular outflow tract (LVOT) that would have prevented the TAVR delivery system from being appropriately positioned and delivered (Fig. 1a, b, arrow indicates calcified aortic valve, arrowheads indicate protruding strut of bioprosthesis). In addition, significant concern was raised for mitral valve-in-valve due to the risk of LVOT obstruction by the leaftlet of the surgical bioprosthesis when pushed down by the transcatheter valve implanted in mitral position as valve-in-valve [1]. Despite her high surgical risk and recent clinical decline, this patient was active and capable of performing all her activities of daily living until recently. After a comprehensive discussion between interventional cardiology and cardiac surgery, the decision was for surgical aortic valve replacement and transcatheter mitral valve-in-valve via left atrium with removal of the leaflets and protruding struts from the LVOT. Ultimately, the goal of this hybrid, non-conventional approach was to minimize the time on pump that this very high-risk patient would need for a double surgical valve replacement while minimizing the possibility of the catastrophic complication of LVOT obstruction after mitral valve-in-valve. During the surgical procedure the strut previously observed on the CT procedural planning was identified in the mid portion of the LVOT (Fig. 2a, arrow). The leaflets of the mitral valve and the strut were cut (Fig. 2b), followed by the implantation of a Sapien3 29 mm valve (Edwards Lifesciences) within the mitral bioprosthesis via direct visualization from the left atrium. No material was obstructing the LVOT post procedure (Fig. 2c). Finally, a Magna Ease 23 mm valve (Edwards Lifesciences) was surgically placed in aortic valve position. Post-operative echocardiography showed no significant paravalvular leak of Sapein3 valve and no evidence of LVOT obstruction (Fig. 3a, b). Patient was discharged on post-operative day 14 in stable conditions. This case emphasizes the utmost importance of detailed computed tomography pre-procedural planning in transcatheter valve therapies, which enabled a customized hybrid approach in this very complex scenario. Ultimately, we were able to minimize the time on pump, which significantly reduces the burden of the surgical procedure, while preventing catastrophic complications such as LVOT obstruction or even an aborted transfemoral TAVR secondary to inappropriate interactions with the surgical mitral valve bioprosthesis. …