Lithotripsy-Assisted Transcatheter Mitral Valve Replacement for Severe Mitral Annular and Valve Calcification
Puvi N. Seshiah, M.D., FSCAI, The Christ Hospital Health Network, Cincinnati, OH
Puvi N. Seshiah, M.D., FSCAI, The Christ Hospital Health Network, Cincinnati, OH
Title
Lithotripsy-Assisted Transcatheter Mitral Valve Replacement for Severe Mitral Annular and Valve Calcification
Introduction
Transcatheter mitral valve replacement (TMVR) is evolving however, limitations include severe calcification of the MV leaflets and mitral annular calcification (MAC), which may be associated with incomplete valve expansion. Shockwave lithotripsy (IVL)–assisted percutaneous mitral valvuloplasty to treat calcific mitral stenosis has been reported. We describe the first human use of IVL-assisted transseptal TMVR with Intrepid valve to treat severely calcified MV in a patient with severe stenosis and regurgitation. Clinical Case
An 83-year-old man with rheumatic mitral and aortic valve disease, prior TAVR presented with worsening HF and was noted to have severe mitral stenosis/MR.
Echocardiogram revealed normal LV function and severe MAC/MVC. The mean mitral gradient was 10 mm Hg, MVA was 0.9 cm2, and MR was grade 3.
Following informed consent for the APOLLO trial, patient was approved for the MAC arm of the trial. To prevent systemic embolization, Sentinel embolic protection of the right innominate and left carotid arteries was performed. Left vertebral artery protection was provided by inflating a 10x40–mm balloon in the left subclavian artery. RFV access was obtained by surgical cut-down, and 22F Dryseal Sheath was inserted through which a Baylis sheath was used to perform TSP. Safari wire was advanced into the LA, and atrial septum was dilated with 14 × 40–mm balloon. A pigtail catheter was advanced into the LV. Safari wire was placed in LV and a 14F Mullins sheath was advanced through which two 0.014-inch wires were placed in LV. Two 8x60–mm Shockwave M5+ balloons were advanced across the MV annulus and Lithotripsy was performed. Safari wire was reinserted into the LV and a 26-mm True balloon was used to perform mitral valvuloplasty. Lunderquist wire was placed into the LUPV. The 37F TMVR sheath was advanced into LA and a 48mm Intrepid valve was advanced into the LV. The valve was deployed. Postdeployment, moderate central MR and a valve gradient of 4 mm Hg were observed. Moderate valve frame deformation was noted in the AP dimension, with complete expansion in the lateral dimension. Postdilation was performed with a 28-mm Z-MED balloon. Valve frame expansion was observed on TEE with grade 2 central MR and MG was 4 mm Hg. This result was considered adequate. The patient remained hemodynamically stable and was discharged on the third postoperative day.
Discussion
TMVR for native valve disease may be a reasonable alternative in patients with high surgical risk, yet MAC and MVC continue to be challenging for both self-expanding valves due to constraints during deployment as well as BEVs, which risk injury and/or rupture of the mitral annulus.
Shockwave intravascular lithotripsy (IVL) of calcified mitral annulus and leaflets before TMVR may improve leaflet pliability, enhance annular compliance, mitigate fibroelastic recoil, and prevent valve frame deformation. Despite the lack of intravascular imaging documentation, we believe that lithotripsy was effective in modifying MAC/MVC in this case, as reflected by an immediate increase (after IVL) in valve dimensions and progressive circularization/expansion of the valve over time following implantation.