12 January 2023: Articles
Challenging Case of Transcatheter Mitral Valve-in-Valve-in-Valve Replacement
Unusual clinical course, Management of emergency careMuhammad H. KhanEF, Nicholas L. BiondiEF, Shaheer ZulfiqarEF, Imran ArifEF, Manisha DasEF, Mehak Budhiraja, Vimal Mehta, Wilbert S. AronowEF, Rishi SukhijaAEF
Am J Case Rep 2023; 24:e938415
BACKGROUND: A 39-year-old man with a complex valvular history of recurrent methicillin-resistant Staphylococcus aureus endocarditis with 2 surgical mitral valve replacements (in 2016 and 2017) followed by transcatheter mitral valve replacement (in 2019) presented with orthopnea, paroxysmal nocturnal dyspnea, chest pain, cough, and progressively worsening dyspnea on exertion.
CASE REPORT: Extensive workup was performed, including transesophageal echocardiogram, which revealed a malfunctioning, severely stenotic bioprosthetic valve. Left and right heart catheterization revealed mild non-obstructive coronary artery disease and severe pulmonary hypertension. Given the patient’s complex medical history, he was deemed to be at an elevated risk for repeat sternotomy and repeat valve replacement surgery. Therefore, he underwent a percutaneous transcatheter mitral valve replacement with a 26-mm SAPIEN 3 Edwards valve placed within the previous 29-mm SAPIEN valve. Post-procedural imaging revealed a well-placed valve with an improved mitral valve gradient.
CONCLUSIONS: This is one of the few rare cases of mitral valve-in-valve via a transcatheter mitral valve replacement approach with successful deployment of a SAPIEN 3 tissue heart valve. The patient experienced significant reversal of heart failure symptoms and improved exertional tolerance following deployment of the valve and was eventually discharged home in a stable condition.
Keywords: Mitral Valve, Mitral Valve Endocarditis, Transcatheter Mitral Valve Replacement
Mitral stenosis (MS) and regurgitation are the most prevalent valvular diseases in the United States and are associated with increased incidence of mortality and heart failure .
Valvular diseases in the past were typically caused by rheumatic heart disease; however, now most valve diseases are degenerative . Infective endocarditis remains uncommon, with an incidence of approximately 2 to 10 cases per 100 000 person-years . It is known that bioprosthetic valves degenerate over time (approximately 15 years), and the criterion standard is reoperation despite its association with higher morbidity and mortality . A valve-in-valve (ViV) treatment strategy with TMVR can be considered as an alternate option in patients with a high surgical risk.
A 39-year-old man was admitted with symptoms of progressively worsening New York Heart Association class IV dyspnea for the past several months. He additionally had orthopnea, paroxysmal nocturnal dyspnea, chest pain, cough, and dyspnea on exertion.
His past medical history included chronic kidney disease, with hemodialysis, and a complex valvular history, starting with a methicillin-resistant
On presentation, his physical examination was remarkable for a normal cardiopulmonary finding, with regular heart rate and rhythm, no murmurs on auscultation, or jugular venous distension on inspection. Trace bilateral pitting edema was present. The pulmonary examination demonstrated a normal respiratory effort, and clear lung sounds were auscultated in all fields.
A transthoracic echocardiogram (TTE) had recently been performed in the outpatient setting, revealing a severe MV stenosis. Initial laboratory workup was largely unremarkable, and no new or ongoing infections were noted. A transesophageal echo-cardiogram (TEE) was performed to further work up his worsening dyspnea, cough, and chest pain, which confirmed a malfunctioning, severely stenotic bioprosthetic valve (Figures 1, 2), with the anterior leaflet fixed in the closed position. Severe stenosis was identified by a velocity time integral ratio of 4.35 and a mean pressure gradient of 12 mmHg at 52 beats per min. Computed tomography of the MV also revealed a severely stenotic bioprosthetic MV (29-mm SAPIEN 3 valve), seated within the surgical valve (29-mm St. Jude Epic bioprosthetic valve), with appropriate size and a low risk for left ventricular outflow tract obstruction (Figures 3, 4). Finally, a left and right heart catheterization were performed, which revealed mild non-obstructive coronary artery disease and severe pulmonary hypertension, with mean pulmonary artery pressure of 50 mmHg. Although his Society of Thoracic Surgeons score was not elevated, given 2 prior sternotomy procedures and a complex medical history including severe pulmonary hypertension, the cardiothoracic surgery team recommended a percutaneous valve-in-valve-in-valve (ViViV) procedure.
The patient underwent a percutaneous transcatheter MV replacement (TMVR) with a 26-mm SAPIEN 3 Edwards valve placed within the previous 29-mm SAPIEN valve with TEE guidance. With careful consideration, we were able to fracture the incompletely expanded SAPIEN 29-mm bioprothetic valve ring, using a 26-mm×4.5-cm true balloon deployed at 14 atm. Figure 5 shows the valve appearance prior to balloon dilatation, followed by the presence of a significant waist (Figure 6), and finally resolution of the waist and obvious fracture of the previous valve (Figure 7). This allowed adequate deployment of the new bioprosthesis (Figure 8). The post-procedural TTE revealed a well-placed SAPIEN TMVR valve with an improved MV gradient of 7 mmHg, down from 12 mmHg, with a new velocity time integral ratio of 1.0 (Figure 9). He was eventually discharged home with significant improvement in his symptoms (New York Heart Association class I).
Bioprosthetic valves have an advantage over mechanical valves because of fewer thrombotic complications and avoidance of anticoagulation, but they degenerate over time needing reintervention. The early use of TMVR for ViV procedures was off label until approval in 2017 by the Food and Drug Administration.
The 30-day mortality rate of the ViV procedure was 3.9% in 2019, down from 8.8% in 2014 . The first ViV TMVR was performed in 2009 via a transapical approach . The trans-apical approach has largely been replaced by the transseptal approach since 2014, from 76% to 3.8% of procedures being performed transapically [3,4]. A prospective registry study measuring 1-year mortality in 1529 patients with degenerated bioprosthetic mitral valves concluded that the transcatheter mitral ViV procedure had high technical success, low 30-day and 1-year mortality rates, and significant improvement of heart failure symptoms [5,6].
While there are few cases of ViViV mitral procedure (11 reported from 2016 to 2019) , the frequency with which ViV procedures are being done is increasing . The Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy registry noted a steady increase in ViV TMVR. From 2014 through 2019, the case load increased 10-fold from 71 to 873 mitral ViV procedures [3,4,7]. Overall, the ViV TMVR has a procedural success rate over 90%, with readily reproducible and predictable results [3,7]. While studies have indicated favorable outcomes for ViV TMVR, comparable results on reversal of heart failure symptoms and sustained valve performance have not been replicated in cases of ViViV TMVR due to the paucity of cases.
This is a unique case of a successful TMVR in a previously placed transcatheter MV inside an original bioprosthetic mitral ViViV, with significant improvement in heart failure symptoms.
FiguresFigure 1.. Pre-procedure transesophageal echocardiogram (TEE): Continuous wave inflow Doppler of mitral valve on TEE showing severe stenosis of bioprosthetic mitral valve with a mean gradiant of 11.72 mmHg. Figure 2.. Three-dimensional image of severely stenotic bioprosthetic mitral valve on pre-deployment transesophageal echocardiogram: Surgeon’s view from the left atrium showing severe leaflet restriction with severely reduced valve opening. Figure 3.. Computed tomography assessment of mitral valve: To assess annular size and to determine appropriate size of the new valve. Figure 4.. Computed tomography assessment of neo left ventricular outflow tract (LVOT): Shows average area of 26.44 mm after valve implantation, which would be low risk for LVOT obstruction. Figure 5.. Prior to dilation: Fluoroscopy shows overlapping previously deployed valve stent struts. Figure 6.. Persisting waist: Fluoroscopy shows significant waist after initial balloon inflation. Figure 7.. After dilation: Fluoroscopy shows resolution of waist and fracture of the stent struts after high pressure inflation of the balloon. Figure 8.. Three-dimensional image of bioprosthetic mitral valve on post-deployment transesophageal echocardiogram: Surgeon’s view showing successful placement of the new bioprosthetic mitral valve with full leaflet opening and improved valve area, as compared with Figure 2. Figure 9.. Post-procedure transesophageal echocardiogram: Continuous wave inflow Doppler of mitral valve post-deployment showing resolution of severe stenosis and an improved mean gradient of 4.16 mmHg.
1.. Nkomo VT, Gardin JM, Skelton TN, Burden of valvular heart diseases: A population-based study: Lancet, 2006; 368(9540); 1005-11
2.. Chambers HF, Bayer AS, Native-valve infective endocarditis: N Engl J Med, 2020; 383(6); 567-76
3.. Urena M, Vahanian A, Brochet E, Ducrocq G, Iung B, Himbert D, Current indications for transcatheter mitral valve replacement using transcatheter aortic valves: Circulation, 2021; 143(2); 178-96
4.. Mack M, Carroll JD, Thourani V, Transcatheter mitral valve therapy in the United States: J Am Coll Cardiol, 2021; 78(23); 2326-53
5.. Stone GW, Lindenfeld JA, Abraham WT, Transcatheter mitral-valve repair in patients with heart failure: N Engl J Med, 2018; 379(24); 2307-18
6.. Whisenant B, Kapadia SR, Eleid MF, One-year outcomes of mitral valve-in-valve using the sapien 3 transcatheter heart valve: JAMA Cardiol, 2020; 5(11); 1245-52
7.. Bapat VN, Mitral Valve-in-valve, valve-in-ring, and valve-in-mitral annular calcification: Are we there yet?: Circulation, 2021; 143(2); 117-19
22 February 2023 : Case reportA 30-Year-Old Woman with an 8-Week History of Anxiety, Depression, Insomnia, and Mild Cognitive Impairment ...
Am J Case Rep In Press; DOI: 10.12659/AJCR.938732
22 February 2023 : Case reportMultidrug-Resistant Kocuria rosea and Methicillin-Resistant Staphylococcus aureus Co-Infection in a Nigeria...
Am J Case Rep In Press; DOI: 10.12659/AJCR.938761
16 March 2023 : Case reportA 64-Year-Old Man Hospitalized for COVID-19 Pneumonia and Treated with Tocilizumab Who Developed Chronic Ca...
Am J Case Rep 2023; 24:e938359
01 March 2023 : Case reportAccelerated Cardiac Allograft Vasculopathy in an Orthotopic Heart Transplant Recipient with Prior COVID-19
Am J Case Rep 2023; 24:e937955
17 Mar 2023 : Case reportDermoid Cyst of the Parotid Gland: Case Report of a Rare Entity and Review of the Literature
Am J Case Rep In Press; DOI: 10.12659/AJCR.939411
17 Mar 2023 : Case reportA Case of a Refractory Bleeding Giant Vaginal Wall Cavernous Hemangioma Successfully Managed with Sclerothe...
Am J Case Rep In Press; DOI: 10.12659/AJCR.939474
16 Mar 2023 : Case reportInitial Thrombocyte Concentrate Transfusion in Woman with Chronic Immune Thrombocytopenia Purpura (ITP) Who...
Am J Case Rep In Press; DOI: 10.12659/AJCR.938752
15 Mar 2023 : Case reportThoracic Epidural as a Rescue Analgesic in a Patient with a Continuous Erector Spinae Plane Block for Rib F...
Am J Case Rep In Press; DOI: 10.12659/AJCR.938875
Most Viewed Current Articles
13 Jul 2022 : Case reportWhistling Scrotum: An Unusual Presentation of Pneumomediastinum in the Setting of an Open Scrotal Wound
Am J Case Rep 2022; 23:e936441
06 Dec 2021 : Case reportLipedema Can Be Treated Non-Surgically: A Report of 5 Cases
Am J Case Rep 2021; 22:e934406
23 Feb 2022 : Case reportPenile Necrosis Associated with Local Intravenous Injection of Cocaine
Am J Case Rep 2022; 23:e935250
07 Dec 2021 : Case reportEdwardsiella tarda: A Classic Presentation of a Rare Fatal Infection, with Possible New Background Risk Fac...
Am J Case Rep 2021; 22:e934347