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Customized Cardiac Care: Percutaneous Valve-in-MAC after Alcohol Septal Ablation
Session:
Sessão Melhores Casos Clínicos
Speaker:
Catarina Oliveira
Congress:
CPC 2024
Topic:
P. Other
Theme:
37. Miscellanea
Subtheme:
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Session Type:
Prémios, Registos e Sessões Especiais
FP Number:
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Authors:
Catarina Simões De Oliveira; Cláudia Moreira Jorge; Joana Rigueira; Rui Plácido; António Fiarresga; Helena Santiago; João Tiago Coelho; Fausto J. Pinto; João Silva Marques
Abstract
<p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">A 81 years old women with a previous history of diabetes, dyslipidemia, atrial fibrillation and embolic stroke without sequelae, presented with heart failure. Transthoracic echo showed normal EF and mitral annular calcification (MAC) leading to mixed moderate-severe mitral disease. On the Heart Team discussion, she was considered a surgical turndown based on anatomy and surgical risk. It was decided to evaluate candidacy for a valve-in-MAC (ViMAC) procedure. </span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">On CT, area was adequate for ViMAC implantation and MAC score predicted low risk of embolization. However, narrow neo left ventricle outflow tract (neoLVOT) area significantly increased the risk of LVOT obstruction. To mitigate that risk, a dual strategy of alcohol septal ablation (ASA) followed by base-to-tip LAMPOON was considered. The patient agreed to this strategy. </span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">ASA involved the identification of a suitable septal branch, followed by using contrast echo to accurately target the basal septum and, finally, selectively injecting alcohol. Persistent heart block led to permanent pacemaker implantation.</span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">Forty-five days after ASA, angioCT revealed a substantial increase in neoLVOT area that was of low risk for LVOT obstruction (figure 1). Therefore, the patient was accepted for percutaneous ViMAC. Given the complexity of this structural heart intervention, a highly specialized approach was adopted for pre-procedural planning. We used patient-specific simulation combined with multimaterial 3D printing to recreate the patient's cardiac anatomy. Then we successfully implanted a 29mm SAPIEN 3 valve into the simulated MAC model in the cath lab (figure 2). </span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">The interventional team reviewed every critical step of the ViMAC procedure and proceeded according to plan: a right femoral venous access was obtained followed by transeptal puncture. A deflectable sheath was used to cross the valve. Septostomy was performed and the 29mm SAPIEN 3 was successfully positioned and implanted under fluoroscopic and transesophageal echo guidance. Final assessment showed low gradient and no perivalvular leak (figures 3 and 4). The patient was discharged 48h after the procedure. One month after the procedure the patient improved symptoms with no further hospital admissions. </span></span></p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:Calibri,sans-serif">To our knowledge, this case reports the first successful percutaneous implantation of a transcatheter prosthesis in a native mitral valve in Portugal. Furthermore, it outlines the relevance of preprocedural planning and the value of adjunctive preprocedural interventions. </span></span></p>
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