Transapical Transcatheter Mitral Valve-in-Valve Implantation: A ...

Transapical Transcatheter Mitral ValveinValveImplantation: A Case SeriesAnson Cheung, Jian Ye, David Wood, Ronen Gurvitch,Samuel Lichtenstein and John WebbDivision of Cardiothoracic surgery and CardiologySt. Paul’s HospitalUniversity of British ColumbiaVancouver, Canada

Presenter DisclosureAnson Cheung, Jian Ye and John WebbThe following relationships exist related to thispresentation:Edwards Lifesciences, Received, Role (Consultant,Speakers Bureau)

Structural Valve Deterioration• Increasing use of bioprosthesis– In younger patients– Expected increase in redo MVR for SVD• High mortality and morbidity of reoperative MV surgery inelderly population• Technical difficulties (injury to grafts and other cardiacstructures and myocardial protection)

Transcatheter ValveinValve ConceptEdwards SapienPericardial ValveCE Perimount

Objectives• Feasibility and Safety of transapical transcathetermitral valveinvalve implantation (TVIVi) inpatients that were deemed too high risk forconventional redo MVR• To study the clinical and hemodynamic outcomes

Case IEcho MVA 0.5 cm 2 MG 17mmHg Severe MR EF 65% PAP 90mmHg

Transapical Transcatheter Mitral ValveinValve Implantation in a Human(Case performed in 2007)A Cheung, J Webb, D. Wong, J Ye Ann Thorc Surg 2009;e18e20

Echo Well seated MG 5mmHg no paravalvular leak

Transapical AV implantation and Mitral ValveinValvefor AS and MV SVD

Results• From July, 2007 to April, 2010• 8 patients underwent transapical TVIVi at St.Paul’s Hospital, Vancouver, Canada• All turned down by >2 surgeons for conventionalredo MVR

Patient Age STS Risk Score(%)NYHAClass1 80 20.6 32 78 16.4 33 80 11.9 44 84 19.0 35 73 18.5 46 77 7.3 37 84 19.1 48 89 28.2 4Mean 81± 5 17.6± 6.2ComorbiditiesCABG/MVRCAD, Pulm HTN, HTN, COPD, A. fib, CRICABG/MVRSevere AS and MV SVD, Isch CM, HTN,A.fib, CRI, HemolysisMVRHTN, COPD, Alcoholic cirrhosisMVRPulm HTN, A.fibCABG/MVR X 2CAD, HTN, A.fib, CRICABG/MVRCAD, A. fib, PVDAVR/MVR, Redo AVR/TV repairA.fib, CRIMVRHTN, A.fib, CRI, COPD, Pulm HTN

Patient Valve Type Failure Mode Valve Age(Yrs)12345678CE Perimount25mmCE S.A.V27mmCE S.A.V27mmMedtronicMosaic 25mmCE S.A.V27mmMedtronicIntact 27mmMedtronicMosaic 23mmCE Porcine29 mmStenosis 7Regurgitation 11RegurgitationStenosisRegurgitationStenosis +RegurgitationRegurgitationRegurgitation13924111011Valve ImplantedCribierEdwards26mmEdwards SAPIEN26mmEdwards SAPIEN26mmEdwards SAPIEN26mmEdwards SAPIEN23mmEdwards SAPIEN23mmEdwards SAPIEN23mmEdwards SAPIEN26mm

• All had successful implantsResults• No hemodynamic instability requiring CPB support• No valve embolization or malpositioning• No apical hemorrhage• No reoperation for bleeding or tamponade

Hemodynamic ResultsPatientMean Gradient(mmHg)Mean Gradient Post (mmHg)Regurgitant GradeRegurgitant GradePost1 17 6 1+ 02 8 9 4+ 03 10 9 4+ 04 18 9 1+ 1+5 11 8 4+ 1+6 20 7 4+ 07 9 6 4+ 18 7 3 4+ 0Mean 17.5 (9,17) 7.5 (6, 9)

• No 30day mortalityResults• One patient died 45 days postop, suffered periop CVA,pneumonia and sepsis• All other patients are alive and in NYHA I/II• Median Followup = 234 days (153, 311)• Longest Followup = 556 days

Summary• Transapical approach offers a direct and precise accessto the MV prosthesis• Transapical mitral valveinvalve implantation istechnically feasible with predictable results

Summary• Provided good early clinical and hemodynamic outcomes– effective in treating prosthetic SVD (Insufficiency andstenosis)– stable valveinvalve configuration– trace or no perivalvular leak– acceptable transvalvular gradient• Valveinvalve becomes more clinical important– more biological prosthesis implanted– advanced age at time of reoperation

Transapical Transcatheter Mitral Valve-in-Valve Implantation: A ...

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