Transseptal mitral valve-in-valve replacement of intra-atrial mitral prosthesis in a patient with severe mitral annular calcification.

Echocardiography after transseptal intra-atrial mitral valve-in-valve replacement.

Mitral valve-in-valve replacement can be performed safely via a high transseptal approach in mitral valves that have been placed within the atrium on polyethylene terephthalate cuffs to avoid mitral annular calcification.

See Commentaries on pages 269, 271, and 273.

Open valve replacement with severe mitral annular calcification carries the risks of embolization, atrioventricular rupture, and circumflex artery impingement. Intra-atrial placement of mitral valve prosthesis using a polyethylene terephthalate graft has been described as an alternative to traditional valve replacement., Although transcatheter mitral valve-in-valve (TMViV) replacement has been well described, we present the first successful TMViV replacement of an intra-atrial prosthesis.

Patient Case

The nature of this study exempted it from requiring University of Florida Institutional Review Board approval and consent per institutional review board policy.

An 80-year-old woman with multiple comorbidities, including atrial fibrillation on apixaban, presented in 2021 with orthopedic injuries following a fall. In 2013, she had undergone mitral valve replacement. Due to extensive mitral annular calcification at that time, an 8-mm polyethylene terephthalate graft collar was sutured to a 25-mm Carpentier-Edwards bovine pericardial prosthesis (Edwards Lifesciences, Irvine, Calif) and the collar was then sutured to the left atrium. Preoperative evaluation after her fall found her to be in congestive heart failure due to bioprosthetic valve stenosis and an immobile leaflet (mean gradient, 13 mm Hg), with mild-to-moderate paravalvular leak at the level of the mitral annular calcification. Computerized tomography angiography demonstrated the bioprosthetic mitral valve, left atrial appendage clip, and mitral annular calcification (Figure 1). The bioprosthetic mitral valve had been positioned 2.5 cm above the level of the annulus in the left atrium (Figure 2).

Figure 1

Preoperative computerized tomography angiography demonstrating intra-atrial prosthetic mitral valve (PMV), severe mitral annular calcification (MAC), and a left atrial appendage clip (LAAC).

Figure 2

Preoperative coronal image obtained by computerized tomography angiography demonstrating the spatial relationships between structures. The prosthetic mitral valve (PMV) is observed in the intra-atrial position, 25 mm above the mitral annular calcification (MAC). Left atrial appendage clip (LAAC) is also demonstrated.

Due to high surgical risk, we proceeded with TMViV replacement. Anticoagulation therapy had been held for more than a week as a result of preoperative evaluation and surgical timing. Three-dimensional transesophageal echocardiography (3D-TEE) was crucial for guiding the unusually superior septal puncture location required, and for crossing the mitral prosthesis because of its anomalous position within the left atrium (Figure 3). The septum was punctured 2 cm superior to the valve to deliver a steerable sheath (Agilus, Plymouth, Minn). 3D-TEE was used to guide a pigtail catheter across the prosthesis for Confida wire (Medtronic, Minneapolis, Minn) placement in the left ventricle apex. (Figure 4, A). A buddy wire was also placed, anticipating that it could be required to maintain the Confida wire in position as the deployment device was advanced (Figure 4, B). However, the Sapien 3 valve (Edwards Lifesciences) was easily positioned within the mitral valve (Figure 4, C), without any requirement for using the second wire. The buddy wire was removed and the valve deployed (Figure 4, D). TEE demonstrated excellent valve function with a mean gradient of 3 mm Hg and unchanged mild-to-moderate paravalvular leak at the level of the annulus (Video 1). Deep venous thrombosis prophylaxis with subcutaneous heparin was administered throughout the patient's hospitalization. She went on to have her orthopedic injuries surgically repaired 4 days after undergoing valve replacement, and her home apixaban was resumed 6 days after that. The patient was discharged to a rehabilitation facility in good condition.

Figure 3

Preoperative 3-dimensional transesophageal echocardiography demonstrating the intra-atrial location of the prosthetic mitral valve (PMV). The polyethylene terephthalate collar (C) used to suture the prosthetic valve to the mitral annulus is also visible.

Figure 4

Intraoperative 3-dimensional transesophageal echocardiography demonstrating transcatheter mitral valve-in-valve replacement of a stenotic intra-atrial bioprosthetic mitral valve. A, A pigtail catheter was placed across the mitral prosthesis after a high transseptal puncture. B, A buddy wire was initially placed across the valve, anticipating it may be required to assist in positioning of the deployment device. C, The deployment device was easily positioned across the valve without any need for manipulation of the buddy wire, which could then be removed. D, The device was then deployed.

Three-dimensional transesophageal echocardiography demonstrating preoperative mitral stenosis secondary to a failed calcified intra-atrial bioprosthetic mitral valve, intraoperative positioning of the valve device across the prior prosthesis, and excellent valve-in-valve function postoperatively. Video available at: https://www.jtcvs.org/article/S2666-2507(21)00428-4/fulltext.

Discussion

With bioprosthetic mitral valve placement increasingly becoming the treatment of choice for patients requiring valve replacement, reoperation for structural valve degeneration is becoming more common. Structural valve degeneration has been linked to younger age at implantation, but not valve size, gender, atrial fibrillation, concomitant procedures, or New York Heart Association functional classification., However, studies have shown patients with smaller (20 or 23 mm) Sapien 3 transcatheter heart valves have increased transvalvular gradients and mortality, in the setting of higher baseline comorbidities. TMViV replacement has been described in more than 1500 patients, with 97% technical success and 5.4% 30-day mortality. Intra-atrial placement of bioprosthetic mitral valve as a management strategy for severe mitral annular calcification should not exclude patients from undergoing TMViV replacement. Successful transcatheter mitral valve-in-valve replacement can be performed safely in intra-atrial valves, using a high transseptal puncture, with excellent results.