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OBJECTIVE: 76 year-old male with worsening congestive heart failure (NYHA III-IV with recent hospitalization) due to severe mitral stenosis and a heavily calcified mitral valve annulus. Past medical history significant for coronary artery disease and myocardial infarction in 2008 with coronary artery bypass grafting and patch repair of left ventricular aneurysm, pacemaker placed in 2010, and transcatheter aortic valve replacement in 2015. Presented in atrial flutter, on Coumadin with INR 2.65.
METHODS: Preoperative assessment:
-Height 171 cm, Weight 81.5 kg, BMI 27.9; Cr 1.42, Alb 3.3, proBNP 6,510, Hgb 14.1, PLT 129.
-Cardiac catheterization: LIMA-LAD and SVG grafts X 2 patent, CO 2.43 L/min -RHC: PCWP 35 mmHg, PA mean 47 mmHg
-TEE: EF 50-55%, Trace AI, AVA 1.64 cm², Mean gradient 13.8 mmHg, Peak Velocity 241 m/s; Mitral regurgitation 2+, Effective Orifice Area 0.6 cm², Severe mitral annular calcification.
-STS PROM 9.186.
RESULTS: Plan: Percutaneous transseptal transcatheter mitral valve replacement (TMVR) with 29 mm Sapien3 valve
OR Course: Uneventful percutaneous access and transseptal placement of 29 mm Sapien3 valve. Noted severe paravalvular regurgitation and second valve placed and post-dilated with complete resolution of paravalvular leak. Subsequent atrial embolization of both valves. Urgent percutaneous cannulation and initiation of cardiopulmonary bypass. Mini-thoracotomy and removal of embolized valves and direct minimally invasive mitral valve replacement.
Outcome: Discharged to home POD 10 and returned for 30-day follow up in NYHA I heart failure with mild paravalvular regurgitation on TEE.
CONCLUSIONS: TMVR for mitral stenosis is a feasible alternative to a high-risk reoperative surgery. Transcatheter therapies have created new complications, such as left atrial valve embolization. Surgeon involvement in TMVR is paramount, as new strategies will be needed to address challenging cases.