Michael Simpson, MD and Isaac George, MD
Columbia University, New York, NY, USA
Essential Operative Steps
- ECG, pulse oximeter, arterial catheter
- Induce general anesthesia
- TEE, foley
- Prep and drape chest, abdomen, and bilateral groins
- Vascular access with percutaneous sutures in bilateral common femoral veins, access in common femoral artery
contralateral to treatment side (prefer right for treatment for easier angle with transseptal access) - Place transvenous pacemaker in right ventricle through contralateral venous sheath, test thresholds, and place on backup
- Dilate treatment side to allow placement of Edwards eheath (14Fr) into the IVC
- Over a 0.032inch wire, advance a transseptal access catheter into the right atrium
- Identify the fossa ovalis and an area appropriate for transseptal puncture using TEE and fluoroscopy
- Transseptal puncture in the posterosuperior aspect of the fossa ovalis and advancing a steerable introducer catheter into
the left atrium while maintaining wire position within the LA - Position MPA (multipurpose angiographic) catheter and floppy wire nearly coaxial to mitral bioprosthesis and cross
carefully with a wire - Advance MPA catheter into the LV and exchange floppy wire for preformed, stiff wire
- Dilate atrial septostomy with a 10/12 x 4cm balloon
- Prepare Sapien 3 delivery system on the back table. Check and re-check valve orientation for ANTEGRADE delivery
- Insert delivery system and dock/align the valve in the IVC as in the descending aorta for TAVR
- Advance the delivery system through the septostomy and across the bioprosthesis
- Position the valve approximately 70% below the annulus to allow for “flaring” of the frame to mitigate against valve
embolization - Induce apnea, begin rapid ventricular pacing, and inflate the balloon to expand the prosthesis
- Assess valve position and function on TEE before removing the device sheath
- Remove vascular access sheaths, tying previously placed percutaneous sutures and holding manual pressure as needed
Potential Complications and Pitfalls
- LVOT obstruction: this is the most devastating complication of transcatheter mitral valve replacement. Mitigation of this
largely occurs preoperatively. Review preoperative multiplanar CT reconstruction and measure neo-LVOT area. Areas
greater than 1.5cm2 are considered adequate remaining area. Consider adjunctive procedures such as laceration of the
anterior mitral leaflet (LAMPOON) or alcohol septal ablation for those patients with prohibitive surgical risk. Note that
alcohol ablation will generally take 1-3 months and requires at least 1.3mm2 - Patient prosthesis mismatch: preoperative imaging and sizing is of paramount importance. Keep in mind that the true
internal diameter of a prosthesis is less than the label size. Identification of the previously implanted prosthesis is key to
allow accurate sizing and to ensure the percutaneous prosthesis is able to fully expand in situ. The mitral valve-in-valve
app is extremely useful here - Vascular access complication: use of ultrasound and fluoroscopy may dramatically minimize this risk
- Significant right-to-left shunt through septostomy: prior to case completion, it is important to use TEE to assess shunting
across the atrial septostomy and to monitor pulse oximetry for desaturation after valve deployment. A newly functioning
mitral valve prosthesis will lower LA pressure and may predispose for right-to-left shunt, especially in patients with
chronic pulmonary arterial hypertension. Persistent hypoxemia may require return to the operating room or catheterization
lab for percutaneous closure - Paravalvular leak: this is a problem especially for transcatheter MVR in MAC as uneven calcium around the annulus can
cause incomplete sealing. If significant, this may need to be addressed percutaneously or may require open/hybrid
intervention. This is one reason why oversizing of the transcatheter heart valve is important - Valve embolization: can occur if Sapien prosthesis is under-expanded and if the valve is deployed in parallel as opposed
to in a “flared” position. Additional volume of saline during deployment will help the valve to anchor more stably.
Embolization is more common in valve-in-ring and valve-in-MAC. More stringent preoperative selection must be
undertaken for these patients - Native leaflet overhang: leaflet overhang from the native anterior leaflet or from the porcine or pericardial leaflets of a
bioprosthetic valve can interfere with transcatheter heart valve functioning. Appropriate positioning of the transcatheter
heart valve can help mitigate this issue; slight ventricular positioning allows the frame of the transcatheter heart valve to
isolate the “native” leaflets
Template Dictation
Preoperative Diagnosis: Bioprosthetic Mitral Stenosis/Mitral Regurgitation
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Transcatheter Transseptal Mitral Valve Replacement with Sapien 3 Ultra
Attending Surgeon: [BLANK]
Attending Cardiologist: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Operative Findings: The patient has severe bioprosthetic mitral valve stenosis with a preoperative mean gradient of
[BLANK]. Preoperative imaging suggested feasibility of transseptal approach, and the mitral neo-annular area sized the Sapien
prosthesis to [BLANK] with adequate neo-LVOT area. The right femoral vein was chosen for device delivery. The patient’s
prior prosthesis was [SIZE and VALVE TYPE].
Description of the Procedure: The patient was brought into the operating room and identification verified. In supine position,
an arterial pressure catheter was placed. General endotracheal anesthesia was induced. The anesthesiologist placed a Cordis
central venous catheter. Periprocedural antibiotics were administered per hospital protocol. TEE confirmed the size of the prior
prosthetic mitral valve. Chest, abdomen, and bilateral groins were prepped and draped in sterile fashion.
Next, arterial, and venous access were obtained in the left common femoral artery and left common femoral vein with 8Fr
sheaths. A single percutaneous suture was placed in each vessel. A transvenous pacemaker was placed in the right ventricle,
tested with appropriate thresholds, and placed on backup at 40 bpm.
Right common femoral venous access was obtained. A percutaneous suture was placed followed by an 8Fr sheath. 5000U of
intravenous heparin was administered through the central line. The right CFV was dilated, and the Edwards E-sheath (14Fr) was
placed in the IVC. A 0.032inch wire was placed in the SVC and a transseptal introducer catheter was advanced without
difficulty. A NRG Baylis radiofrequency transseptal needle was introduced through the catheter and the system was brought
down to the right atrium under TEE and fluoroscopic guidance. The fossa ovalis was identified and a suitable spot in the
posterosuperior aspect of the fossa was identified for transseptal puncture. The septum was crossed without difficulty and the
catheter was advanced to the left atrium. A Baylis (0.025inch atraumatic pigtail wire) was inserted into the left atrium and an
Agilis steerable introducer catheter was then exchanged over this wire. A 5Fr MPA catheter and floppy wire were introduced
through the Agilis catheter and positioned appropriately. The bioprosthetic mitral valve was crossed with the floppy wire. The
MPA catheter was advanced into the LV. A preformed, stiff (e.g. Confida) wire was exchanged and placed in the LV. Next,
the septum was dilated with a 10/12×4 balloon, and the balloon was removed.
On the back table, the Sapien 3 Ultra valve was crimped and loaded onto the delivery system. Orientation was checked for
antegrade delivery of the valve. Next, the Sapien valve was inserted into the sheath and docked in the IVC over the Confida
wire. The valve was actively flexed, and the nose cone passed through the septum. The nose cone and valve were then slowly
passed across the bioprosthetic valve, with some manipulation, and positioned for deployment.
After proper positioning, the valve was deployed under apnea and rapid pacing with 70% of the valve frame below the neoannulus. The valve was otherwise well-seated. TEE revealed [TRACE/MILD] regurgitation through the valve and confirmed
no right to left shunt through the septostomy. After acceptable function was confirmed by echo, the device sheath was removed.
The valve sheath was removed from the femoral vein and manual pressure was held.
The sheaths in the groin were closed with the previously placed Perclose devices and manual pressure was held until hemostasis
was achieved. Protamine was given.
All instrument, sponge, and needle counts were confirmed to be correct, twice, at the end of the surgical procedure. The patient
was subsequently transferred to the postoperative cardiac surgical intensive care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
Which of the following is NOT associated with LVOT obstruction after transcatheter mitral valve replacement?
A. Ventricular septal hypertrophy
B. More obtuse aortomitral angulation
C. More ventricular positioning of the transcatheter heart valve
D. Increased left ventricular cavity size
E. Valve-in-ring compared to valve-in-valve
Answer: D. Increased left ventricular size, which may be associated with treatment for MR versus MS, will generally provide
more space between the transcatheter heart valve and the septum and increase the residual LVOT area. Each of the other
answer choices increase the risk of LVOT obstruction.
Sources
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