Percutaneous Management of Bioprosthetic Mitral Valve Dehiscence With Combined Valve-in-Valve Replacement and Paravalvular Leak Closure: A Case Report
Presenter
Hani Alturkmani, University of Arkansas for Medical Sciences, Little Rock, AR
Hani Alturkmani1, Jack Xu, MD1, Adib Chaus, MD2, Srikanth Vallurupalli, M.D.1 and Gaurav Dhar, MD, FSCAI3, (1)University of Arkansas for Medical Sciences, Little Rock, AR, (2)University of Arkansas for Medical Sciences, Des Plaines, IL, (3)Rush University, Chicago, IL
Title
Percutaneous Management of Bioprosthetic Mitral Valve Dehiscence with Combined Valve-in-Valve Replacement and Paravalvular Leak Closure: A Case Report
Introduction
Prosthetic paravalvular leak (PVL) is a serious and life-threatening complication of mitral valve replacement. Valve dehiscence is a rare but serious cause of prosthetic paravalvular leak (PVL) with high risk of morbidity and mortality. Surgery is the first-line approach in such cases, however, it carries a high risk of mortality. Evidence and experience of percutaneous repair of valve dehiscence is limited. Here we present our experience with a patient with mitral bioprosthetic valve dehiscence secondary to infective endocarditis who underwent a percutaneous mitral valve-in-valve and PVL repair.
Clinical Case
A 53-year-old male with a history of infective endocarditis of the mitral valve secondary to intravenous drug use status-post 31-mm Medtronic Mosaic bioprosthetic valve replacement presented 5 months after valve replacement with dyspnea. Transthoracic echocardiogram showed a rocking motion of the prosthetic valve suggestive of valvular dehiscence. Patient developed cardiogenic shock unresponsive to medical treatment. Impella CP was placed leading to hemodynamic stability. Transesophageal echocardiogram showed a crescentic shape of the dehiscence in the 5-7 o’clock region measuring 1.6 cm in circumference by 0.6 cm in maximal width with severe paravalvular regurgitation. His Society of Thoracic Surgeons score was 74.2%. In view of the large paravalvular regurgitation and prosthetic instability, a salvage procedure with a mitral valve-in-valve (ViV) in order to stabilize the valve and paravalvular leak closure was planned. Patient underwent a successful percutaneous transcatheter bioprosthetic Mitral ViV replacement with a 29-mm S-3 Ultra valve. Biological valve fracture of the 31 mm Mosaic valve (true inner diameter 26 mm) was attempted with a 28-mm Tru Balloon but was unsuccessful. Severe PVL persisted. An 8-mm ventricular septal occluder was implanted to reduce regurgitation and stabilize the valve. Valve stability was achieved and there was a modest reduction in regurgitation. This reduction led to a significant clinical improvement and Impella CP was removed. He was discharged one week later with a plan for re-do surgical valve replacement in 6 months if patient is able to maintain sobriety.
Discussion
Prosthetic valve dehiscence is a challenging complication of mitral valve surgery with a high risk of mortality. Re-do surgery is the traditional approach in such cases when surgical risk is not prohibitive. Evidence and experience with percutaneous management of valve dehiscence remains limited. Here we present a case of mitral valve dehiscence and cardiogenic shock. Patient was at a prohibitive risk for surgery and underwent successful percutaneous valve-in-valve and deployment of a septal occluder resulting in a reduction of PVL and hemodynamic stability. This shows that percutaneous valve-in-valve and paravalvular plugs might be reasonable, albeit last resort, options. A challenge in our case was the inability to fracture the surgical valve swing ring despite multiple attempts, which necessitated the use of a septal occluder. It is worth noting that complete resolution of mitral regurgitation is not always necessary to produce clinical improvement. Even a modest reduction in the severity of PVL allowed the patient to be weaned-off circulatory support.