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Special Delivery: Transeptal Transcatheter Mitral Valve-in-valve Replacement With A 65 Cm Delivery Sheath
Iverson E. Williams, BS1, Omar M. Sharaf, BS
1, Michael R. Massoomi, MD
2, Albert R. Robinson III, MD
3, Thomas M. Beaver, MD, MPH
4;
1University of Florida, College of Medicine, Gainesville, FL, USA,
2University of Florida Health, Division of Cardiology, Gainesville, FL, USA,
3University of Florida Health, Department of Anesthesia, Gainesville, FL, USA,
4University of Florida Health, Division of Cardiovascular Surgery, Gainesville, FL, USA
BACKGROUND: Transeptal valve-in-valve transcatheter mitral valve replacement (TS ViV-TMVR) is a safe intervention for comorbid patients with histories of sternotomy. However, TS ViV-TMVR can be hindered in patients with complicated septal anatomy. A 73-year-old woman with a history of two-vessel coronary artery bypass grafting and a bioprosthetic MVR via an open sternotomy transeptal approach presented with acute on chronic congestive heart failure. Pre-op catheterization showed a pulmonary artery pressure of 100/40 mmHg and a pre-op echo showed a mean gradient (MG) of 19 mmHg and mitral regurgitation. Due to comorbidities, she had a hypertrophied, scarred interatrial septum (IAS), which required septal dilation with a nonstandard 22 mm balloon and a nonstandard 65 cm Dry seal sheath (Gore Inc, Flagstaff, AZ, USA) to deliver a 26 mm Ultra Resilia valve (Edwards, Irvine, CA, USA).
METHODS: The TS ViV-TMVR was performed in a hybrid operating room where ultrasound was used to access the left common femoral vein for temporary pacing, the right common femoral vein for primary access, and the Baylis Versacross System (Baylis Medical, Burlington, MA, USA) for transeptal puncture. Fluoroscopy guided the Agilis steerable catheter for crossing the Storq wire through the mitral valve, which was exchanged for a Confida wire (Medtronic, Minneapolis, MN, USA). At this point, traditional technique requires inserting a 14 French sheath (Edwards LifeSciences Corp., Irvine, CA, USA) and septostomy with a 16 mm balloon (Bard Peripheral Vascular, Tempe, Arizona). However, the patient’s thickened IAS required up-dilation to a 22 mm balloon. Despite up-dilation, valve delivery was unsuccessful. The team decided to deploy a 65 cm Dry seal sheath, for pulmonary valve replacements, to complete valve delivery.
RESULTS: The patient tolerated the TS ViV-TMVR well. Post-op echo showed a well-seated valve with no evidence of paravalvular leak or insufficiency, with MG of 4 mmHg and residual left-right atrial shunt. She was stable and discharged one week later. One month later, echo showed improved symptoms with a good functioning MV.
CONCLUSIONS: TS ViV-TMVR with a larger balloon catheter and an extended Dry seal sheath allows lifesaving surgery for high-risk patients with complicated septal anatomy.
Deployment of TMV via 65cm sheath.
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