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New York City Conference

Back to 2014 Annual Meeting Abstracts


Case: Complete Percutaneous Combined Antegrade Transseptal-Transapical Delivery of a Valve-in-Valve Within a Degenerative Mitral Bioprosthesis
Sean Wilson, Chad Kliger, Anja Summers, Gila Perk, Vladimir Jelnin, Itzhak Kronzon, Gregory P. Fontana, Nirav Patel, Luigi Pirelli, Carlos Ruiz.
Lenox Hill Hospital, New York, NY, NY, USA.

OBJECTIVE: •87 year old female with a history of mitral valve disease s/p biological 25mm Carpentier-Edwards Perimount mitral valve replacement who presented with congestive heart failure. Echocardiography revealed severe prosthetic stenosis with mean gradient of 13mmHg. Patient was deemed high surgical risk, with a STS score of 15%. After multi-disciplinary team review, decision was made for complete percutaneous mitral Valve-in-Valve (ViV) implantation using a transcatheter Sapien valve (Edwards Lifesciences) via a novel approach - combined antegrade transseptal-transapical.
METHODS: Pre-procedural imaging performed with transesophageal echocardiogram and helical cardiac CTA. A biological Edwards mitral bioprosthesis was visualized with dense calcification and restricted movement of leaflets. Mean antegrade mitral gradient - 13mmHg. Fluoroscopy provided visualization of radiographic markers of valve and appropriate positioning of Sapien valve within Edwards prosthesis. Using CT-Fluoro fusion imaging (HeartNavigator, Philips Healthcare), segmentation of Edwards bioprosthesis was performed and allowed for determination of appropriate c-arm view for ViV positioning and deployment. Landmarks were determined for appropriate sites of transseptal and transapical access such that creation of arteriovenous (AV) rail allowed for completely percutaneous coaxial valve deployment.
RESULTS: Directed transseptal and transapical access were performed using fusion imaging. Creation of an AV rail was achieved and septostomy performed using a 12x40mm peripheral balloon. 23mm Sapien valve was mounted onto a 24mm BiB balloon (NuMed, Hopkinton NY) and delivered unsheathed. Valve was positioned using the AV rail with varied tension and the transapical sheath to prevent forward movement. Inflation of the inner balloon for further fine-tuning. CT-fluoro and Echo-fluoro fusion imaging (EchoNavigator, Philips Healthcare, Andover MA) guidance were performed to aid in positioning and successful ViV deployment.
CONCLUSIONS: For symptomatic patients with severe mitral bioprosthetic failure deemed high surgical risk, off-label Sapien ViV can be performed using a completely percutaneous approach. With the guidance of fusion imaging, transseptal and transapical access can be achieved while creating an AV rail. The use of a BiB balloon with the AV rail provides total operator control and coaxial ViV delivery.


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