Challenging Case. 77 year old man 1/24/2018. Two months PTA AVR with 21 Edwards Magna and VSD repair for S. Aureus endocarditis

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1 Vumedi January year old man Challenging Case Paul Sorajja, MD Roger L. and Lynn C. Headrick Family Chair Valve Science Center, Minneapolis Heart Institute Foundation Abbott Northwestern Hospital Disclosures: none Two months PTA AVR with 21 Edwards Magna and VSD repair for S. Aureus endocarditis Now hospitalized for heart failure 1

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6 Key Points Beware of pacemaker wires when snaring in RA Rail creation and anchor wire technique essential for fistula closure Thank you! Tel: Register Now: 6

7 Percutaneous Mitral Valve Repair for Treatment of Left Ventricular Outflow Tract Obstruction following Surgical Mitral Valve Repair Santiago Garcia, MD Associate Professor of Medicine University of Minnesota, Division of Cardiovascular Disease, Minneapolis, MN Medical Director, Structural Heart Program Minneapolis VA Healthcare System, Minneapolis, MN phone: Objective Describe a novel treatment of mitral regurgitation due to systolic anterior motion (SAM) of the mitral valve leaflet associated with left ventricular outflow tract (LVOT) obstruction following surgical mitral valve repair. Background Approximately 4.7% to 8.0% of patients undergoing surgical mitral valve repair develop SAM peri- or post-operatively. 1,2,3 Decreased incidence with incomplete annuloplasty band rather than a complete ring. 3 Increased incidence of SAM with left ventricular ejection fraction greater than 60% and posterior leaflet resection. 3 Patients with persistent SAM with more than mild MR and/or a LVOT gradient greater than 50 mm Hg should be considered for early reoperation according to their symptoms, severity of excess leaflet tissue prolapsing into the LVOT and the patient s comorbidities Varghese et al. J Thorac Cardiovasc Surg. 2012;143( 4 Suppl):S Miura et al. Gen Thorac Cardiovasc Surg. 2011;59(11): Loulmet et al. J Thorac Cardiovasc Surg. 2014;148(6):

8 Risk Factors for SAM after MV repair Patient-related Presence of excessive leaflet tissue (Barlow's disease) with a tall posterior leaflet (>15 mm) Ratio between the heights of the anterior and posterior leaflets 1.3 Aorto-mitral plane angle <120 Distance between the interventricular septum and the mitral leaflet coaptation point <25 mm Thick basal interventricular septum (>15 mm) Small and hyperkinetic left ventricle Anterior displacement of the papillary muscles Procedure-related Inadequate reduction of the posterior leaflet height (which still remains >15 mm) Insertion of a small prosthetic ring Prevention of SAM after MV repair: Role of TEE Aorto-mitral plane Angle < 120 Distance between IVS and leaflet coaptation point < 25 mm Basal septum > 15 mm Alfieri O, Lapenna E. Systolic anterior motion after mitral valve repair: where do we stand in 2015? Eur J Cardiothorac Surg 2015;48: Surgical techniques for prevention/treatment of SAM Edge-to-edge Repair 2

9 Case Presentation Patient Description 63 year old male Mitral valve repair (P2) plus annuloplasty ring in 2015 (OSH) for acute chordal rupture complicated by cardiogenic shock Presents 1 year after surgery with dyspnea and dizziness with minimal activity such as walking, bending to tie shoes Very active prior to surgery TEE: SAM and mitral regurgitation following surgical mitral valve repair LVOT peak gradient of 100 mmhg severe mitral regurgitation, peak LV-LA gradient 200 mmhg 1.5 cm of redundant anterior leaflet SAM and LVOT gradient with Dobutamine 10 mcg/kg/min 3

10 Severe MR, peak LV-LA gradient 200 mmhg Treatment Discussion Surgical re-operation considered an option if needed Novel approach to attempt treatment with a MitraClip and possibly avoid a repeat sternotomy TS Puncture 4

11 TS Puncture Trajectory and Grasping 3D and LVOT view Trajectory and Grasping 3D and LVOT view 5

12 Clip Partially closed, tissue bridge Clip Partially closed, tissue bridge Dobutamine (20 mcg) Challenge After Clip: No residual MR or LVOT obstruction 6

13 Dobutamine (20 mcg) Challenge After Clip: No residual MR or LVOT obstruction Post Clip LVOT gradient Fluoro image of clip and ring 7

14 Discussion Successful percutaneous mitral valve repair for post-operative SAM and mitral regurgitation Avoided repeat surgery Novel approach for treatment of post-operative SAM and mitral regurgitation Conclusion The role of surgical intervention after unsuccessful MitraClip has been well described. In the EVEREST II trial, 23% of patients treated with percutaneous repair needed surgery for residual MR III/IV The role of percutaneous repair after failed surgical repair is not well established Successful percutaneous treatment of post-operative SAM and mitral regurgitation following surgical mitral valve repair using MitraClip is feasible and effective Thanks for your attention, Santiago Garcia, MD 8

15 Complicated Cases in the Management of Valve Disease Alan Zajarias, MD Co-Director Center of Valvular Heart Disease Structural Interventional Fellowship Director Clinical History 69 y/o male with Dyspnea to 100 ft Lower extremity edema Abdominal fullness Large volume paracenteses q 2-3 weeks Early satiety Hospitalized x 4 over 2 months Diuresis Heart failure management PMHx Ross procedure in 1999 Paroxysmal atrial fibrillation Sick sinus syndrome S/p pacemaker Cirrhosis (cardiac) Meds Digoxin mg QD Warfarin Metoprolol 50 mg QD Amiodarone 200 mg QD Aldactone 75 mg AM, 50 mg PM Furosemide 80 mg QD Potassium 40 meqtid Metformin 1000 mg BID Exam and Laboratory Data Exam: BP: 130/75 mmhg HR: 99 RR: 18 O2: 98% Ill appearing HEENT: Scleral icterus Neck: + JVD to 10 cm Cor: RRR tachycardic, S3, IV/VI DM at base II/IV SM at base and IV/VI DM at LUSB Lungs: crackles Abdomen: distended with fluid wave LE: 3+ edema bilaterally Labs Cr: 2.05 mg/dl BUN 27mg/dl K: 5 mmol/l Alb: 3.1 g/dl Tbil: 2.0 g/dl AST 26 U/L Plts: 175 BNP: 830 pg/ml INR: 3 (on coumadin) MELD Score: 1

16 Echocardiography LVEF: 28% RV function: nl Moderate to Severe AI PHT: 330 ms Severe PI PHT: 129ms Moderate TR RHC + Pulmonary Angiography RA: 15 mmhg RVSP: 38/15 mmhg PA: 36/15 mmhg CI: 1.8 L/m/m 2 CT Imaging Annulus LVOT Sapien 3 29 mm valve 0% oversize at annulus Undersized at LVOT 2

17 Multidisciplinary Discussion High risk for conventional surgery Re-do setting Cirrhosis Double valve replacement Recommendation Transcatheter pulmonic valve replacement Transcatheter aortic valve replacement Coronary Angiogram Melody Placement (TPVR) Created landing zone with 40 x10 mm and 30 mm x 10 mm Excel Stent 3

18 Melody Deployment 22 mm Melody Valve Pulmonic Angiography TAVR Procedural Plan TEE for guidance Safari 2 wire for support 29 mm Sapien 3 Slow inflation Nominal prep +2 cc TAVR Deployment 4

19 Post Valve Replacement Pulmonic gradient Aortic gradient Follow up Discharged to home No repeat hospitalizations since discharge No recurrent paracentesis Conclusions Transcatheter options exist for selected patients with failed Ross procedures. Careful planning of complicated cases is critical for procedural success. Involvement of Pediatric Interventionalists or other specialists is always helpful in specific cases. 5