From the *Department of Cardiothoracic Surgery, Oslo University Hospital; and †Faculty of Medicine, University of Oslo, Oslo, Norway.
Accepted for publication July 27, 2012.
Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, May 30–June 2, 2012, Los Angeles, CA USA.
Disclosure: The authors declare no conflict of interest.
Address correspondence and reprint requests to Gry Dahle, MD, Department of Cardiothoracic Surgery, Oslo University Hospital, Rikshospitalet, Postboks 4950, Nydalen, 0424 Oslo, Norway. E-mail: firstname.lastname@example.org; email@example.com.
Abstract: A 71-year-old woman with severe congestive heart failure and failed mitral valve repair was referred for surgery. Because of her low ejection fraction, a valve-in-ring procedure was suggested. There was a great difference in the given size for the 34-mm Carpentier-Edwards-Physio-Ring and the biggest available transcatheter valve of 29 mm from Edwards. Therefore, we did a “bench test.” We expanded a 29-mm Edwards SAPIEN-XT aortic valve in a 34-mm Carpentier-Edwards-Physio-Ring. It fitted well and turned out circular with good coaptation of the leaflets. Thereafter, a successful transapical mitral valve-in-ring implantation on cardiopulmonary bypass was performed, and additional leads for cardiac resynchronization was placed.
Mitral valve repair with annuloplasty ring is the treatment of choice for some patients with mitral regurgitation, but recurrence may occur, necessitating reintervention.1 For functional mitral valve regurgitation, the prevalence of recurrent regurgitation ranges between 11% and 22%.2,3
The operative risk at reoperation is significantly higher than in the primary operation.
It has previously been demonstrated that a transcatheter valve-in-valve technique may reduce operative risk.4 However, the experience with valve-in-ring procedures is limited. Only a 26-mm Edwards SAPIEN-XT aortic valve (Edwards Lifesciences Inc, Irvine, CA USA) has been implanted in a 28-mm Carpentier-Edwards-Physio-Annuloplasty-Ring (CE-Physioring).
In our case, the difference between the given size of the CE-Physioring and the biggest available transcatheter aortic valve was much greater. However, we demonstrate a successful transapical implantation of a 29-mm Edwards SAPIEN-XT aortic valve in a failed mitral valve repair with a 34-mm CE-Physioring.
A 71-year-old woman was referred. Three years previously, she had a 34-mm CE-Physioring implanted in addition to artificial chordae as well as a 30-mm Edwards MC3 Tricuspid Annuloplasty-Ring. Except for atrial fibrillation postoperatively, the initial repair was successful.
She developed severe mitral regurgitation and congestive heart failure. The ejection fraction was reduced to 17%; she had declive edema and pulmonary hypertension (50 mm Hg) and deteriorated to New York Heart Association functional class III-IV. The Logistic EuroSCORE was 28. Standard open heart surgical procedure was considered too dangerous. Neither was she a candidate for the MitraClip-system (Abbott, Evalve, Menlo Park, CA USA) because of structural dearrangement of the mitral leaflets. Therefore, a transcatheter valve-in-ring procedure was considered.
We evaluated the ring size on three-dimensional transesophageal echocardiography, and measurements obtained of the oval-shaped CE-Physioring were in accordance to the dimensions given by the company (Figs. 1 and 2). An important question was how a circular-shaped aortic catheter valve would fit into this semirigid annuloplasty ring and whether the big gap in valve sizes would give paravalvular leak between the ring and the valve. We therefore tried the 34-mm CE-Physioring on different circular valve sizers, and the ring fitted very tightly on a 27-mm CarboMedics sizer (Sorin Group USA, Inc, Arvada, CO USA) (Figs. 3A, B). In a “bench test,” we balloon-expanded a 29-mm Edwards SAPIEN-XT aortic valve in a 34-mm CE-Physioring. When expanded with the recommended volume of fluid for the balloon, the valve was a bit loose in the ring. We therefore added 2 mL of extra volume to the balloon to perform a postdilation (Fig. 3C). The balloon then had no tendency to “dog-bone shape” and the valve was expanded as circular as possible and there was good coaptation of the leaflets (Figs. 3D, E).
A valve-in-ring operation was performed in our hybrid operation room. We did a small left-sided anterolateral thoracotomy in general anesthesia and made two pledget purse-string sutures on the apex of the left ventricle. We prepared Edwards Lifesciences femoral venous cannula no. 24 and Medtronic (Minneapolis, MN, USA) for peripheral cannulation in the groin and EOPA cannula no. 22 for the artery. A pacing lead to the right ventricle was inserted from the left femoral vein. The apex was punctured while being on partial extracorporeal perfusion. A soft wire was introduced followed by a multipurpose sheath. Through this, an Amplatzer SuperStiff wire (0.035 in.) (Boston Scientific, Natick, MA USA) was positioned through the mitral orifice into the left atrium, aiming for the right upper pulmonary vein. We advanced the Ascendra 1 introducer sheath through the apex and made no predilation of the mitral valve. A 29-mm Edwards SAPIEN-XT aortic valve was inversely mounted on the delivery balloon and introduced through the sheath and the mitral ring. The valve was positioned under guidance of fluoroscopy and transesophageal echocardiography so that 60% of the height was in the left ventricle (Figs. 4A, B). Under rapid ventricular pacing, the Edwards SAPIEN-XT valve was balloon-expanded in the CE-Physioring. During insufflation, the ring changed from the originally oval-shaped to almost circular form. A grade II paravalvular leak was noted. We therefore added 2 mL extra volume to the balloon and did a postdilation of the valve (Fig. 4C) that became round shaped (Fig. 4D). Thereafter, the paravalvular leak was almost negligible and there was no intravalvular leak. An epicardial pacing lead on the left ventricle for later cardiac resynchronization treatment was applied. We inserted a 50-mL intraaortic balloon pump (CS300; MAQUET Cardiopulmonary AG, Hirrlingen, Germany) from the femoral artery and came off bypass.
The patient was extubated after 2 hours, and the intraaortic balloon pump could be removed the first postoperative day. A transvenous pacemaker lead and the generator for the cardiac resynchronization treatment were established 1 week after the valve implantation.
At follow-up 3 months later, the patient was in New York Heart Association class I-II, and on echocardiography, there was a minimal paravalvular leak, there was no significant gradient, and the ejection fraction had increased to 30%.
Mitral valve repair is the treatment of choice for mitral valve regurgitation, providing excellent operative results and superior survival and long-term outcomes, as compared with mitral valve replacement. However, postoperative recurrence of mitral valve regurgitation may occur in some patients.2 With the aging population, an increasing number of patients may come for primary intervention or reoperation. Consequently, the operative risk will markedly increase because of advanced age or comorbidities.
The operative risk for residual mitral regurgitation after repair or for degenerated bioprosthetic valves significantly outweighs the risks for first-native valve repair or replacement.2 The encouraging results of transcatheter heart valve implantations in general have prompted several experienced centers to explore the feasibility of using these techniques in patients with failed mitral and aortic bioprosthesis.3,4
So far, little is known about the feasibility of catheter techniques in patients with failing mitral valve annuloplasty. Given an experimental report5 and case reports,6,7 we knew it was feasible to perform a valve-in-ring procedure. Both transapical and transseptal accesses have been reported.6–8 So far, only the 26-mm Edwards SAPIEN-XT valve has been used in a 28-mm CE-Physioring. One of our concerns was the oval shape of the CE-Physioring versus the circular shape of the Edwards SAPIEN-XT valve. We have previously shown in a case report that the oval shape of the Edwards SAPIEN-XT valve may cause intravalvular leak because of “sagging” and “stretching” of the cusps (case report at Dallas-Leipzig valve meeting 2010). However, the experimental work of the Leipzig group5 had shown the adaptability of the CE-Physioring into a circular form at balloon insufflation. However, our biggest concern was the discrepancy in size between the ring and the largest balloon-expandable valve available. Two case reports have shown that a 26-mm Edwards SAPIEN-XT valve would fit into a 28-mm CE-Physioring. Our preprocedural bench testing made us believe that the 29-mm Edwards SAPIEN-XT valve would fit in to a 34-mm CE-Physioring, which was confirmed during the procedure.
We believe that the valve-in-ring concept in the future may play a significant role in reducing the redo-mortality in patients with failed mitral valve repairs. In this case, we have shown that it is also feasible to implant a 29-mm Edwards SAPIEN-XT valve in a 34-mm CE-Physioring, despite the given big difference in sizes. This is of great importance because many CE-Physiorings used are of the sizes of 30 to 34 mm.
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