Transcatheter Edge-to-Edge Mitral Valve Repair Following Surgical Annuloplasty Ring Dehiscence
Presenter
Abhushan Poudyal, MD, Oregon Health & Science University, Portland, OR
Abhushan Poudyal, MD1, Karla Asturias, MD1, Katherine Lutz, MD1, Smriti Khanal, MD2 and Firas E. Zahr, MD, FSCAI3, (1)Oregon Health & Science University, Portland, OR, (2)Jefferson Einstein Hospital, Philadelphia, PA, (3)OHSU Knight Cardiovascular Institute, Portland, OR
Title:
Transcatheter Edge-to-Edge Mitral Valve Repair Following Surgical Annuloplasty Ring Dehiscence
Introduction:
Transcatheter edge-to-edge mitral valve repair (TEER) is an established therapy for patients with both primary and secondary mitral regurgitation (MR) with elevated surgical risk. TEER can be technically challenging in patients with dehisced prior annuloplasty ring; there is paucity of data on this specific issue, limited to case reports, case series and registry data. Prior studies have reported success with the use of MitraClip device (Abbott). PASCAL Precision System (Edwards) is a novel TEER platform, similar to MitraClip in principle. We report the first case where PASCAL device was used to treat recurrent primary MR with concomitant ring dehiscence.
Clinical Case:
77-year-old male with prior surgical mitral valve (MV) annuloplasty (30 mm Edwards Physio) for MV prolapse presented with progressively worsening exertional dyspnea and volume overload. Transthoracic (TTE) and transesophageal echocardiogram (TEE) showed severe MR with multiple complex jets, dehisced annuloplasty ring in the anterior and medial aspects and dilated left ventricle. With TEE and ICE (intracardiac echocardiography) guidance, TEER was initially attempted via around-the-ring approach, however was not successful. TEER was then successfully performed via through-the-ring approach with placement of two PASCAL Ace devices leading to reduction of MR from severe to trivial. Patient’s dyspnea and volume overload significantly improved on follow up.
Discussion:
Mitral annuloplasty ring dehiscence can occur early or late after surgery as a result of sutures pulling out of the annulus tissue due to increased suture tension. Some of the predisposing factors include endocarditis, severe mitral annulus calcification, and undersized ring. Posterior annulus is most frequently involved, probably due to limited visibility and tendency to take insufficient suture bites in order to avoid left circumflex artery injury. Also, as compared to anterior mitral annulus which is collagen-rich, posterior annulus is formed by myocardium, therefore it is prone to annular dilation and suture dehiscence. Anterior ring dehiscence, as noted in our case, is less common. If surgical risk is prohibitive, transcatheter options can be considered. A dehisced ring, which is out of plane with the native annulus, is unfavorable for transcatheter valve-in-ring intervention since it risks inadequate sealing or even further ring detachment, therefore TEER is an alternative strategy. Prior studies have reported success with the use of MitraClip device, both via around-the-ring and through-the-ring approaches. The present report is the first to describe successful TEER in the setting of dehisced mitral annuloplasty ring using the PASCAL device leading to significant reduction in MR severity accompanied by marked clinical improvement.