Procedural TEE for Native Mitral Valve-in-Valve (VinV) and Valve-in-Ring (ViR)
March 3rd, 2018
G. Burkhard Mackensen, MD, PhD, FASE Professor & Chief, Division of Cardiothoracic Anesthesiology
Department of Anesthesiology & Pain Medicine UW Medicine Research & Education Endowed Professor in Anesthesiology
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DISCLOSURE
•NONE
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Focus issue on Interventional Echocardiography in the APRIL 2018 edition of JASE
April 2018Volume 31, Issue 4
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CASE#1:ComplexMAC
• 67yoF–currentinpaDentwithseveresymptomaDccalcificmitralstenosisadmiKedforconsideraDonofTMVR
• PMH:severeCOPD,2renaltransplantssecondarytourethralreflux(1981,2002),CADs/pPCI8/30/17,parathyroidectomy,OSA,HTN,HLD,PVD
• Symptoms:currentlyhospitalizedforprogressiveSOB;NYHAIII-IV
• Ht=154cmWt=76.5KgBMI=32.3kg/m2
• BNP=NACr=2.1mg/dL
• STSscore:12%forsurgicalmitralreplacement
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CASE#1:Operabilitystatement
• "GiventhepaDent'scomorbidiDes,butspecificallyimmunosuppression,severeperipheralvasculardisease,butspecificallychronicobstrucDvepulmonarydisease,IbelievethepaDentisapoorsurgicalcandidatewithamuchmoresignificantriskofpulmonarycomplicaDonsorhealingcomplicaDons.”
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CASE#1:TransthoracicEchoMean PG = 13 mmHgEcho Variable (TTE) Measure
PeakMVG(mmHg) 26-28
MeanMVG(mmHg) 13-15
CalculatedMVAbyPHT(cm2) 1.0
SeverityofMR Mild-Mod
SeverityofAR Trace
EjectionFraction(%) 70%
PASP(mmHg) 37-42
CASE#1:CTassessment,LVOTevaluationand3Dprinting
Aorto-mitral angle: 47°
LVOT Obstruction evaluation:
Valve Position BaselineLVOTsurfacearea(mm2)
PredictedNeo-LVOTSurfacearea(mm2)
26S360LV/40LA 302.1 95.6
80LV/20LA 319.4 37.5
26S360LV/40LA
26S380LV/20LA
Courtesy of Dee Dee Wang MD, Henry Ford Hospital
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CASE#1-Question:whatshouldbedonenext?
1. ForgetaboutTMVR-theriskofLVOTobstrucDonistoolarge
2. PaDentshouldundergoalcoholablaDontoincreaseLVOT
3. Considerlepatrialaccess/surgicalhybridapproachforTMVRandresecDonoftheanteriormitralvalveleaflet
4. PlanforLAMPOONprocedurefollowedbyTMVR
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CASE#1-Answer:whatshouldbedonenext?
1. ForgetaboutTMVR-theriskofLVOTobstrucDonistoolarge
2. PaDentshouldundergoalcoholablaDontoincreaseLVOT
3. Considerlepatrialaccess/surgicalhybridapproachforTMVRandresecDonoftheanteriormitralvalveleaflet
4. PlanforLAMPOONprocedurefollowedbyTMVR
TranscatheterMitralValveImplantationrisksLVOTObstruction
• Thevalveimplantdisplacestheanteriormitralleaflettowardstheseptum• Currentoptions
– DenyTMVI– Surgicalanteriorleafletresection–thoracotomy/cardiopulmonarybypass– Alcoholseptalablation–sacrificesmyocardium/conductiontissue,requiresthickseptumwithappropriate
perforator,delaysprocedureby4-6weeksinsymptomaticpatients– LAMPOON:LacerationoftheAnteriorMitralleaflettoPreventOutflowObstruction
JMKhan,JACCCardiovascInterv.2016;Sep12,9(17):1835
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LacerationoftheAnteriorMitralleaflettoPreventOutflowObstruction
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CASE#1:TransesophagealEcho-procedure
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CASE#1:TransesophagealEcho-procedure
DeepTGviewofLVOT PWDopplerinLVOT
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CASE#1:TEE-ApproachingAMLandLAsnare
WireapproachingAMLfromaorDcvalve LAsnare
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CASE#1:TEE-valueofproceduralmonitoring
Wiresrelaxed,MRimproved
WiretensioncausingsevereMR
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CASE#1:TEE-LAMPOONhappening
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CASE#1:TEE-importanceofimage-guidance
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CASE#1:TEE-LAMPOONhappening
LaceraDonofAMLcausingsevereMR
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CASE#1:TEE-afterTMVR(VinV)
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CASE#1:TEE-afterTMVR(VinV)
CASE#1:TEE-afterTMVR(VinV)
LVOT Mean PG = 2 mmHg
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CASE#2:ComplexMACinpatientwithAVR
• 71yearoldfemalepaDentwiths/pmechanicalAVRin1999,PCI/stentsin2007andCABGin2010.
• NowpresentswithsymptomaDcsevereMSandMAC,porcelainaorta,deemedatprohibiDveriskforREDOsurgery
• Pulmonaryarteryhypertension• Elevatedwedgepressures(28/41/27)• ElevatedcreaDnine• PaDentwasexcludedfromMITRALstudyduetohighLVOTobstrucDon
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CASE#1:InitialCT
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CASE:InitialTEEimages
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CASE:InitialTEEimages
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CASE:InitialTEEimages
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CASE:InitialTEEimages
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• Transapicalaccessestablished• TestedandopDmizedincadavericspecimen(MarkReismanandDmitryLevin)
• LAMPOONapproachfromLVtoundersurfaceofanteriormitralvalveleafletaimingformiddleofA2
• TEEandFluoroscopyguidancetoopDmizeposiDon• TranseptalapproachforTMVR,advancingvalveintoLA• LAMPOONfollowedbydeployment
HowtocircumventmechanicalAVandstilldoLAMPOON?
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CASE:proceduralimaging
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Challenginghemodynamicsduetowires
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PiercingofAML
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MoreMRafterLAMPOON
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Valve-in-nativeValve:deployment
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TMVRresult
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TMVRresult
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FinalTMVRresult
• SuccessfulprimarytransapicalLAMPOONandTMVR• ValueofpreparaDons(cadavericspecimen)• GreatteameffortwithJamieMcCabe,GabrielAldea,MarkReisman
• ExperDseofNIHteamaroundDrs.R.Ledderman,J.Khan
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CASE#3:failedMVannuloplasty
• 74y.oM• PMH:s/pMVring2010,PPM2010,HTN,HLD,AFib,ischemicCMP,priorMI(1997,2010)LVEF~30%
• uncontrolledDM,hypothyroidism,CKD(creaDnine2.0)• Symptoms:NYHAII-III• Ht=188cmWt=93kgBMI=26.32kg/m2• BNP=282pg/mL(5/23/17)Cr=2.00mg/dL(5/23/17)• STSscore:8.99%formitralreplacement
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CASE#3:initialassessmentwithCTandechocardiography
RAO 52
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CASE#3:initialassessmentwithCTandechocardiography
CASE#3:3DTEEduringdeploymentofTMVRinring80/20deploymentofa29Sapien3
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CASE#3:3DTEEduringdeploymentofTMVRinring
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CASE#3:FluorodeploymentofTMVRinringandTEEpost
CASE#3:Post-proceduralassessmentwithTEE
Utility of islice to assess LVOTCASE#3:Post-proceduralassessmentwithTEE
Utility of islice to assess LVOTCASE#3:Post-proceduralassessmentwithTEE
CASE#3:Post-proceduralassessmentwithTEE
AV
LA
LV
CASE#3:Post-proceduralassessmentwithTTE
• Echocardiographyiskeytodeterminingcomplexmitralvalvepathologyandsuitabilityfortherightpercutaneousapproach.
• 2Dand3DTEEisinvaluableforpercutaneousproceduralguidance,confirmingsuccess,andexclusionofcomplications.
• Theroleofinterventionalechocardiographywillincreasewiththedevelopmentofnovelnewdevices&therapiesfortheMV.
Conclusion
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THANK YOU
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@gb_mackensen
https://www.linkedin.com/in/gbmackensen/
