A 59-year-old female highly symptomatic patient (functional class NYHA IV) with severe aortic and mitral valve stenosis combined to mild mitral regurgitation, was evaluated for a valve procedure by the institutional heart-team. She had undergone previous open mitral commissurotomy in 1979, and percutaneous mitral balloon valvuloplasty in 1989 and 2001. She suffered from persistent atrial fibrillation, severe chronic obstructive pulmonary disease, sleep apnea syndrome. Surgical valve replacement was deemed high risk, since she presented with a porcelain ascending aorta as well as massive calcifications of the left atrial wall (Fig. 1. a/b). Euroscore II and logistic Euroscore score were 10% and 17% respectively. Decision was made towards a transapical approach as a double-valve procedure. Preoperative imaging including angio-CT and transesophageal echocardiography (TEE) is demonstrated in Fig. 1. The mean transvalvular aortic gradient was 55 mmHg and the residual effective valve orifice area was 0.4 cm2. The preoperative left ventricular ejection fraction (LVEF) was measured at 55%. Furthermore, preoperative TEE revealed a LVOT diameter of 17 mm and a thickness of the subaortic septum at 14 mm. The aortic annulus perimeter 72.7 mm and perimeter-derived diameter 23.1 mm was measured using OsiriX MD DICOM viewer (© Pixmeo SARL) and 3Mensio (Pie Medical Imaging). The mitral valve showed a mean gradient of 12 mmHg with a residual valve orifice area of 0.57 cm2 calculated according to the pressure half-time method. Maximal diameter of the left ventricular outflow tract was 19 mm (Fig. 1.c). The aorto-mitral angle (AMA) was measured with 109° (Fig. 1 b) by 3Mensio (Pie Medical Imaging). The preoperative coronary angiogram revealed no signs of coronary artery disease. Furthermore, the examination revealed a moderate to severe post-capillary pulmonary hypertension with a mean of 44 mmHg.
The procedure was performed under general anesthesia utilizing both fluoroscopy and transesophageal echocardiography. A left mini-thoracotomy incision in the 5th intercostal space, pre-dilatation of the aortic valve was performed with a 20 mm balloon and a 23 mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA) was implanted under rapid ventricular pacing (Fig. 2a). The intraoperative TEE showed a very good aortic valve function without paravalvular regurgitation (Fig. 2b).
Following the aortic valve procedure, repeated mitral balloon valvuloplasty was attempted using first a 28 mm Inoue balloon inserted through the apex and then a 30 mm Osypka balloon (Fig. 3a). The echocardiography showed a slight decrease of the mitral valve gradient to a mean value of 9 mmHg, but a moderate mitral valve regurgitation. Due to the insufficient dilatation of the mitral valve an attempt was undertaken to implant a 27 mm repositionable Lotus Valve System (Boston Scientific, Marlborough, MA) without sheath, directly through the exposed apex (Fig. 3b).
Immediately after the implantation of the Lotus valve, the patient developed profound hypotension. On echocardiography, severe obstruction of the left ventricular outflow tract (LVOT) due to anterior displacement of the thickened and partially calcified anterior native mitral valve leaflet was detected (Fig. 3c/d). The Lotus valve was partially recaptured and a second implantation was attempted with the valve positioned slightly higher into the left atrium, but LVOT-obstruction persisted. The valve was removed, leaving the native mitral valve with a transvalvular gradient of 4 mmHg, with mild mitral valve regurgitation.
The patient was extubated in the hybrid room and had an uneventful recovery. She was discharged to the rehabilitation clinic 9 days after the procedure. Echocardiography at one month showed mild aortic regurgitation and a moderate mitral valve stenosis with a mean gradient of 8 mmHg. Furthermore, the patient reported about an improvement of physical capacity after the intervention and rehabilitation.
