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Innovative Solution in Redo Cardiac Surgery: valve-in-valve TAVI System for Mitral Valve Dysfunction
Session:
Casos Clínicos: Cardiologia de Intervenção
Speaker:
Ana Catarina Relvas Novo
Congress:
CPC 2024
Topic:
H. Interventional Cardiology and Cardiovascular Surgery
Theme:
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Subtheme:
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Session Type:
Sessão de Casos Clínicos
FP Number:
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Authors:
Catarina Relvas Novo; João Lopes Cardoso; Nelson Santos; Fátima Neves
Abstract
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">This is a case of a a 64-year-old woman with atrial fibrillation previously submited to a mitral valve replacement, tricuspid annuloplasty, and left atrial appendix occlusion using an external clip device. At the time her post-operative period was marked by an episode of type 2 heparin-induced thrombocytopenia (HIT). and after discharge she was left on simple antiplatelet therapy with acetylsalicylic acid. </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">One year after surgery the patient presented symptoms of acute heart faillure and after further work up with transesophageal echocardiography she was diagnosed with severe mitral valve thrombosis and dysfunction. She was immediatly started on anticoagulation but as her condition worsened the patient was presented to our centre and it was decided to proceed with surgical intervention for both thrombus removal and valve replacement.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">A right mini-thoracotomy with peripheral femoral cannulation was chosen as a minimally invasive technique that is commonly preferred for complex reoperations due to its ability to avoid major complications associated with redo sternotomy. Due to the patient's previous diagnosis of HIT we chose bilvarudin for anticoagulation strategy during cardiopulmonary bypass (CBP).</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Once on CBP, on a beating heart, the left atrium was opened revealing several adherent atrial wall and valve thrombi that were removed. However, upon approaching the mitral prosthesis, it was found that its structure was extremely adhered to the mitral annulus in a tilted frozen position due to the external clip occluder. Attempting to remove it could result in an atrioventricular disruption or circumflex artery damage. </span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">The patient needed a solution as fast and as simple as possible for a valve replacement and so it was decided to implant a trans-aortic valve system inside the previous mitral valve structure. Following removal of the valve leaflets and thrombi, a balloon-expandable 29mm TAVI was implanted with direct vision. Off-pump intraoperative transesophageal echocardiogram confirmed the valve was well-positioned and well-functioning with no left ventricular outflow tract obstruction.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">Despite challenges in weaning the patient from invasive ventilation, she exhibited a favourable postoperative course with minimal cardiovascular support requirements. Serial transthoracic echocardiograms consistently showed excellent surgical results and approximately one month postoperatively, the patient was transferred to a local hospital to continue respiratory therapy and cardiac rehabilitation.</span></span></p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif">This case emphasizes the critical role of a multidisciplinary approach in managing complex cases involving multiple comorbidities and previous surgical interventions. Furthermore, it underscores the benefits of employing minimally invasive techniques in redo cardiac surgeries to reduce surgical trauma and enhance postoperative recovery.</span></span></p>
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