2023 FSA Podium and Poster Abstracts

P008: TRANSCATHETER VALVE-IN-VALVE MITRAL VALVE REPLACEMENT VIA TRANSAPICAL APPROACH IN A PATIENT WITH AN EXTENSIVE CARDIAC SURGICAL HISTORY AND SEVERE PULMONARY HYPERTENSION: A CASE REPORT.
Miguel A Escanelle, MD; Josef Israeli, BA; Yiliam Rodriguez, MD; University of Miami Miller School of Medicine

Introduction: In developed countries, patients undergoing mitral valve replacement (MVR) for MS tend to be older and typically suffer from multiple comorbidities. High surgical risk renders a significant number of patients ineligible for redo surgical mitral valve replacement (SMVR), which is the gold standard for patients who previously underwent an MVR.

Methods: 63-year-old Caribbean-born woman with a complex medical and surgical history. Her conditions include rheumatic heart disease complicated by MS status post SMVR, CAD s/p CABG, ostium secundum ASD s/p percutaneous closure with Amplatzer septal occluder, HF NYHA Class IV, AF on anticoagulation, severe pHTN, IDDM, COPD, HTN and HLD. Patient presented with progressive dyspnea at rest. TTE showed a severely dilated LV, mild global hypokinesis with an EF of 45-50%, a mean pressure gradient across the bioprosthetic MV of 25 mmHg, an effective orifice area (EOA) of 0.6 cm2 indicated severe MS.

Results: A right arterial line and internal jugular catheter were placed; induction and intubation followed uneventfully. TTE was used to locate the LV apex and improve precision of the surgical incision. The initial assessment with TEE showed a well seated Amplatzer septal occluder with no interatrial shunt. Three-dimensional TEE showed a severely stenotic bioprosthetic MV, a systolic regurgitant jet and turbulent flow through the bioprosthetic MV during diastole (Figures 3 and 4) with a mean pressure gradient of 23 mmHg. Access to the ventricular apex was obtained by a 3-inch anterolateral left minithoracotomy at the fifth intercostal space in the area marked by the TTE. The apex was punctured, and a guidewire was advanced into the LA through the stenotic bioprosthetic MV under TEE guidance. Next, a pigtail catheter was advanced over the guidewire into the LA. A Sapien 3 26mm bioprosthetic valve was deployed under rapid ventricular pacing (180 bpm). A well seated bioprosthetic MV with adequate opening and without evidence of paravalvular leak was visualized (Figure 6 and 7). The mean pressure gradient was 3 mmHg.

Discussion: Transcatheter valve interventions have emerged as an alternative to surgical redo procedures and opened new treatment possibilities to patients for whom traditional surgery is not an option. Transcatheter structural valve interventions require high levels of technical proficiency by the teams; the interventionalists must possess surgical and procedural expertise, and the anesthesiologists require expert level echocardiographic proficiency paired with experience in complex hemodynamic management. Anesthetic and hemodynamic management tend to be particularly challenging since these patients commonly have significant medical comorbidities. The anesthesiologist’s echocardiographic guidance is crucial during the intra-operative period because of its real-time imaging capabilities, low interventional risk, and minimization of the patient’s exposure to contrast. At each step the anesthesiologist must remain in constant communication with the interventionalists. The period immediately after MV deployment is particularly critical to the anesthesiology team for several reasons; one must carefully monitor for LVOT obstruction, watch out for device migration, evaluate, and communicate the placement and function of the new prosthesis to the interventional team, and be vigilant for hemodynamic instability since it is most common during this period.