Associazione Nazionale Medici Cardiologi Ospedalieri



Severe mitral regurgitation treated with transcatheter aortic valve implantation in mitral ring (TMViR): a case report.

Vitale Carlo Pisa(Pisa) – S.D Emodinamica Azienda Ospedaliero Universitaria Pisana | Giannini Cristina PISA(PISA ) – S.D Emodinamica Azienda Ospedaliero Universitaria Pisana | Costa Giulia Pisa(Pisa) – S.D Emodinamica Azienda Ospedaliero Universitaria Pisana

Introduction: The increasing prevalence of mitral regurgitation (MR), combined with a growing population of elderly patients at risk of being unsuitable for surgical options, has led to a greater interest in the use of less invasive treatments such as transcatheter heart valve (THV) implantation. This case involves the use of transcatheter aortic valve implantation in a patient with a previous mitral annuloplasty (TMViR).

Case presentation:A 77-year-old woman had previously undergone mitral annuloplasty (Physio Ring II 32 mm, Medtronic), Neocord implantation and closure of the posterior commissure for severe MR due to anterior leaflet prolapse. She presented to our attention with worsening dyspnea (NYHA Class III) and a sudden weight gain. Transesophageal echocardiogram (TEE) revealed findings indicative of a previous mitral annuloplasty failure, with residual severe MR along with severe tricuspid regurgitation (TR). The case was discussed in the Heart Team and given the elevated surgical risk and the patient ‘s anatomical unsuitability for edge-to-edge therapy, it was decided to perform a TMViR implantation. Under echocardiographic guidance and general anesthesia, right common right femoral vein access was obtained. After transseptal puncture, predilation of the interatrial septum was performed with balloon (Evercross 12 mm, Medtronic). Subsequent access to the left ventricle was achieved with a 6F PigTail catheter, and a stiff exchange guide (Safari S, Boston Scientific) was used to advance the 16Fr Delivery system. With the assistance of TEE, aortic valve implantation on the mitral ring was performed (Sapien 29 mm, Edwards Lifesciences) with rapid pacing via transvenous temporary PM placed in right ventricle (Spikeflow, Fiab). At the end of the procedure, two closure systems (Proglide, Abbott) were used for right femoral vein access. Post-implantation TEE showed a trivial paravalvular leak external to the annulus and a mean transvalvular gradient of 5 mmHg. The postoperative course proceeded without complications, facilitating the patient ‘s discharge on the third postoperative day. Currently no further hospitalization in the last 6 months.

Conclusion:Despite surgical intervention remaining the gold standard in treating severe MR in patients who have undergone a previous annuloplasty, in patients at high surgical risk for a re-operation, who are not eligible for other percutaneous options, TMViR could be a safe and effective option for treatment.