The complex interactions between these anatomic structures result in the exclusion of a considerable number of patients (60% to 70%) at the time of screening ( 6). Known risk factors include left ventricular hypertrophy, pronounced septal thickness, an aortomitral angle of <90°, a small ventricular cavity, and a long anterior mitral leaflet ( 5). LVOTO is a potentially severe complication of TMVI, and pre-operative planning is essential to identify patients at risk ( 4). The patient recovered uneventfully with rapid alleviation of dyspnea. No significant increase of the LVOT gradient was observed. Under transesophageal echocardiographic guidance, the tether was manually pulled out of the left ventricle by 1.4 cm, which resulted in improved apposition of the valve frame and almost abolished the anterior PVL ( Figure 6B, Video 7). The apical pad was unlocked and the remaining length of the tether secured with a clamp. Transapical valve retrieval using a dedicated tool was trained before the intervention. The redo procedure was performed with a primed heart-lung machine in the hybrid room in case of valve dislocation. IVS = interventricular septum.Īfter interdisciplinary discussion, the decision was made to perform a valve retensioning procedure using the previous thoracotomy 11 weeks after TMVI, with the aims of reducing PVL, treating hemolysis, and resolving symptoms.
(B) Improved apposition of the valve after successful retensioning with PVL abolishment and open LVOT. (A) Left ventricular outflow tract (LVOT) view of the Tendyne valve showing worsening paravalvular leak (PVL) (arrow) due to valve loosening. Transesophageal echocardiography showed an increase of the PVL ( Figure 6A, Video 6) related to the atrialization of the MV bioprosthesis. Progressive hemolytic anemia was considered the main reason for persistent dyspnea and cardiac recurrent decompensation. Hemolytic parameters were elevated and haptoglobin was not detectable, with a minimum hemoglobin level of 80 g/l ( Figure 5).
A slightly atrial position of the valve with mild anterior paravalvular leak (PVL) was accepted to ensure a sufficient LVOT area ( Figure 3D, Video 5).Ī few weeks later, the patient was rehospitalized with permanent atrial fibrillation and clinical signs of decompensated heart failure. The self-expanding mitral bioprosthesis was then deployed ( Video 4) and the tether secured at the left ventricular apex. Analysis of pre-procedural cardiac computed tomography yielded a sufficient systolic simulated neo–left ventricular outflow tract (LVOT) area of 285 mm 2 ( Figure 2A) using a 35-mm low-profile valve placed with 6° of posterior bias ( Figures 2B and 2C).Įvolution of Hemodynamic Parameters During Tendyne Valve ImplantationĪBP (s/m/d) = arterial blood pressure (systolic/mean/diastolic) CVP = central venous pressure LVOTO = left ventricular outflow tract obstruction pCO 2 = carbon dioxide pressure. Because of apical fixation, the system can be retensioned using the same surgical access.
The system consists of a porcine bioprosthesis mounted in a self-expanding D-shaped Nitinol stent fixed at the apex of the left ventricle by a tether secured by a pad.
Therefore, transcatheter mitral valve implantation (TMVI) with the Tendyne system (Abbott Vascular, Santa Clara, California) was evaluated. The Society of Thoracic Surgeons risk score was 7.8%, and the European System for Cardiac Operative Risk Evaluation II score was 8.1%.Ī third open-heart surgical procedure was deemed high risk by the Heart Team, and the patient was not eligible for transcatheter edge-to-edge repair, because of leaflet calcification in the grasping area ( Figures 1A and 1B, Videos 1 and 2). Progressive coronary artery disease was excluded by coronary angiography revealing patent grafts, and the mean invasive aortic transprosthetic gradient was stable (14 mm Hg, planimetric aortic valve area 1.2 cm 2).
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