Valve-in-Valve-in-Ring: A Bailout Strategy to Tackle Paravalvular Leaks due to Device Malapposition.

A 55-year-old male with a history of severe organic mitral regurgitation treated with surgical mitral valve (MV) repair was referred for a transcatheter MV replacement due to recurrent regurgitation. After the release of the first transcatheter MV, a severe paravalvular leak coming from the lateral side was observed. To promptly tackle this issue, a second valve with further postdilation was successfully implanted and the paravalvular leak disappeared. This case highlights the feasibility of implanting a second valve in case of severe paravalvular leaks after MV-in-ring procedures due to device malapposition. Copyright:

INTRODUCTION

Mitral valve (MV) surgery for recurrent regurgitation after MV repair (MVR) is a high-risk procedure. Transcatheter valve-in-ring had recently emerged as a valid alternative to treat MVR failure in high-risk and fragile patients.

CASE REPORT

We present a case of a 55-year-old male with a history of severe organic mitral regurgitation (MR) treated with MVR (valvuloplasty and semi-rigid complete ring [CE Physio-ring II 30 mm]) who became symptomatic for dyspnea (New York Heart Association [NYHA] Class III) 4 years after surgery. The transesophageal echocardiographic examination showed a recurrent posterior leaflet prolapse at the level of P1 and P2, a posteromedial billowing (P2-P3), a cleft in the middle of the central scallop (P2), and a trivial para-annular regurgitation with preserved ring stability (Figure 1, Panel a and Supplemental). Due to comorbidities, the patient was deemed to be at very high risk for surgery and after the heart team discussion he underwent a valve-in-ring transfemoral percutaneous procedure and a 26 mm Edwards Sapien 3 Ultra valve was implanted.

Figure 1

(a) Transesophageal color three-dimensional echocardiogram showing the regurgitant jet due to posterior mitral leaflet prolapse 4 years after the first intervention. (b) Multidetector row computed tomography image showing a sagittal view of the mitral valve. (c) Transesophageal color three-dimensional echocardiogram showing the paravalvular leak after the first transcatheter valve implantation. (d) Caudal left anterior oblique fluoroscopy image of the second transcatheter valve implantation. (e) Transesophageal color three-dimensional echocardiogram showing no paravalvular leak after the second valve was implanted. (f) Continuous Doppler of the mitral prosthetic valve showing a stable mean gradient of 8 mmHg at 30-day follow-up

The procedure was planned using multidetector row computed tomography and echocardiographic data (Figure 1, Panels a-b) and was monitored with transesophageal echocardiography and fluoroscopy (Figure 1, Panels c-d). After the valve was released, a severe paravalvular leak coming from the lateral side was observed (Figure 1, Panel c), probably due to the high position of the sealing skirt in the lateral portion of the stented valve. To promptly tackle this issue, a second valve with further postdilation was successfully implanted (Figure 1, Panels d-e and Supplemental) and the paravalvular leak disappeared (Figure 1, Panel e and Supplemental Video 3). At the end of the procedure, no paravalvular leaks were detected (Figure 1, Panel e) and only a mild increase of the MV mean gradient (8 mmHg) with normal estimated pulmonary pressures was present. At 1-month follow-up, the patient was asymptomatic for exertional dyspnea (NYHA functional Class I) and the echocardiographic parameters remained stable (Panel F) without any dilatation of the right heart chambers or increase in pulmonary pressures.

DISCUSSION

Acute procedural success rates of valve-in-ring procedures are estimated to be around 70%,[1] primarily limited by paravalvular leaks, device dislocation, and left ventricular outflow tract obstruction.[1] In the case presented, we report a MV-in-valve-in-ring procedure as a feasible bailout strategy to overcome valve-in-ring complications such as device malapposition resulting in persistent MR after the procedure. In the most recent transcatheter MVR registry, intra-prosthetic anterograde mean gradient reported at follow-up was 6.7 + 3.1 mmHg[2] and is comparable with the final result of this case (8 mmHg) despite the two valves implanted.

Probably, novel technological tools such as virtual simulation and three-dimensional heart models may be useful in selecting the best procedural strategy and prosthesis to prevent potential complications that may occur during MV-in-valve, valve-in-ring, or valve-in-mitral annular calcification implantation. Nevertheless, despite appropriate preprocedural planning, unpredictable scenarios may appear and this case highlights the feasibility and potential utility of implanting a second valve in case of severe paravalvular leaks after MV-in-ring procedures due to device malapposition.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.