Case report.
A 75-year-old woman who had previously undergone mitral valve
replacement seven years earlier with an Edwards Magna 31mm valve
(Edwards Lifesciences) that was complicated by severe left ventricle
ejection fraction (LVEF) decrease (visually estimated at 25%) and
hemicolectomy was admitted for progressive dyspnea and reduced
functional capacity. She was anticoagulated for paroxysmal atrial
fibrillation. Transthoracic echocardiography (TTE) showed a severely
reduced LVEF at 30% and severe mitral stenosis (mean gradient: 25 mmHg
at 108 beats per minute (Figure panel A and Supplementary file video 1),
valve area at 0.7cm2 by direct planimetry using
3-dimensional transesophageal echocardiography (TEE)) with restricted
leaflet mobility (Figure panel B). After Heart-Team discussion, a second
mitral valve replacement was deemed at too high risk considering the
LVEF. We decided to perform a transseptal TMViV using a 29mm Edwards
Sapien S3 transcatheter heart valve (THV) mounted on a transfemoral
Edwards Commander Delivery System in an antegrade position.
After positioning a Sentinel cerebral protection device (Boston
Scientific) in the brachiocephalic trunk and the left carotid artery, we
punctured the right femoral vein, performed a transseptal puncture
followed by a dilatation of the septum by an inflation of a 12x40 mm
Powerflex Pro 0.035 balloon (Cardinal Health TM). Subsequently, a medium
Agilis steerable transseptal sheath (Abbott Vasc) was advanced to
facilitate the advancement of an extra-small 0.035 Safari guidewire
(Boston Scientific) into the LV apex through a 6 French pigtail
catheter. After optimal positioning under fluoroscopic and TEE guidance,
the balloon-expandable valve was deployed under rapid pacing at 180 bpm
(Figure panel C) with significant mean gradient reduction from 25 to
3.6mmHg post-procedure (Figure panel D) and no residual regurgitation.
Of note, the baseline gradient was overestimated due to tachycardia.
Panel E of the figure (and Supplementary file video 2) shows fully
opened leaflets at 3-dimensional echocardiography. After retrieval, the
Sentinel device showed multiple micro debris (Figure panel F). At 1
year, the patient was in a functional class New York Heart Association I
with transprosthetic mean mitral gradient of 7 mmHg. Despite optimal
heart failure treatment, LVEF remained severely reduced (30%) and the
patient underwent primary prevention insertion of an implantable
cardioverter defibrillator.