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Percutaneous implantation of a Sapiens 3 valve in valve in mitral position
Session:
Prémio Melhor Caso Clínico
Speaker:
Miguel Martins de Carvalho
Congress:
CPC 2022
Topic:
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Session Type:
Prémios
FP Number:
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Authors:
Miguel Martins de Carvalho; Ricardo Alves Pinto; Tânia Proença; Pedro Grilo; Carlos Xavier Resende; Sofia Torres; Ana Filipa Amador; Catarina Martins da Costa; João Calvão; Catarina Marques; André Cabrita; Mariana Paiva; Rui André Rodrigues; João Carlos Silva; Filipe Macedo
Abstract
<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif">Currently, the treatment of most of the valvopathies that require intervention is surgical. The transcatheter aortic valve replacement (TAVR) is a well-established procedure to treat patients with symptomatic severe aortic stenosis at increased or prohibitive surgical risk. However, the transcatheter access to the mitral valve is more difficult. We describe a case of a patient who underwent transcatheter mitral valve intervention with a TAVR valve.</span></span></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif">An 85 years old male, with known medical history of hypertension, dyslipidemia and atrial fibrillation, was submitted to aortic and mitral replacement surgery with biological prothesis (aortic Perimount 23, mitral Carpentier Edwards SAV 29), and a De Vega tricuspid annuloplasty in 2011. He remained in NYHA functional class II until 2020, when he developed signs of congestive Heart Failure and worsening shortness of breath. An echocardiogram was performed (October 2020), revealing evidence of mitral bioprothesis disfunction, with severe regurgitation consisting of 2 jets – the most important directed posterior-laterally and to the left atrial appendage, due to prolapse of a cusp. The aortic bioprothesis had high gradients (mean 27 mmHg), compatible with moderate obstruction. The biventricular systolic function was preserved and the patient had signs of important pulmonary hypertension (PASP 64+20 mmHg). Due to advance age, frailty and having undergone previous cardiac surgery, the risk of a new surgery was deemed too high. Therefore, it was decided to perform a transcatheter mitral valve-in-valve implantation of an Edwards Sapiens 3 Ultra 29. We used an antegrade approach and the valve was inserted via trans-septal puncture (preceded by a 14mm balloon dilatation), with 3D transesophageal echocardiogram and fluoroscopy guidance. During balloon dilatation there was no evidence of left ventricle outflow tract obstruction (LVOTO). After the valve implantation, a small lateral peri-prothesis leak was observed. There were no signs of interference with the adjacent cardiac structures. The mean left auricle-left ventricle gradient was 5 mmHg. As a consequence of the procedure, small atrial sept defect (ASD) with bidirectional shunt was created. There was no periprocedural complications. The patient clinical status improved and was discharged 5 days after the procedure. </span></span></span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:"Times New Roman",serif"><span style="font-size:11.0pt"><span style="font-family:"Calibri",sans-serif">This was one of the first time in which a percutaneous prothesis was implanted in the mitral position in our center. There is growing experience in transcatheter procedures in other valves than the aortic. The main limitation to this technic are native mitral valves, which have a higher incidence of LVOTO. This procedure can be a safe alternative in high surgical risk patients with severe mitral bioprothesis disfunction and should be considered in these patients. More studies are needed and dedicated valves and deployment devices need to be developed.</span></span></span></span></p>
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