Transcatheter Mitral Valve Implantation Research Articles

TCT-940 A Comparative Study of TENDYNE and Traditional Transcatheter Mitral Valve Implantation on Reverse Remodeling and Outcome

TCT-940 A Comparative Study of TENDYNE and Traditional Transcatheter Mitral Valve Implantation on Reverse Remodeling and Outcome

Delayed Intervention’s Impact on Transcatheter Mitral Valve Implantation Strategy

Delayed Intervention’s Impact on Transcatheter Mitral Valve Implantation Strategy

Transcatheter Mitral Valve Implantation in a Failed Surgical Ring: Limitations of the Interventional Approach

Transcatheter Mitral Valve Implantation in a Failed Surgical Ring: Limitations of the Interventional Approach

Outcomes after transcatheter mitral valve implantation in valve-in-valve, valve-in-ring, and valve-in-mitral annular calcification.

We aimed to evaluate transcatheter mitral valve implantation (TMVI) using predominantly balloon-expandable transcatheter heart valves (THV) in patients with a landing zone for a percutaneously delivered prosthesis. Patients with a degenerated mitral valve bioprosthesis, annuloplasty ring, and mitral annulus calcification (MAC) considered at high surgical risk currently represent a treatment challenge. TMVI is an alternative treatment option. Retrospective analysis of patients with symptomatic degenerated mitral valve bioprosthesis, or annuloplasty ring, and MAC treated with TMVI between November 2011 and April 2021. Endpoints were defined according to Mitral Valve Academic Research Consortium (MVARC) criteria and included device and procedure success at 30 days as well as mortality at 30 days and 1 year after the procedure. A total of 77 patients underwent TMVI (valve in valve [ViV = 56], valve in ring [ViR = 11], and valve in MAC [ViMAC = 10]). There was a trend toward higher technical success (all = 93.5%, ViV = 96.4%, ViR = 90.9%, ViMAC = 80%, p = 0.06) and lower 30-day (all = 11.7%, ViV = 10.7%, ViR = 9.1%, ViMAC = 20%, p = 0.49) and 1-year mortality (all = 26%, ViV = 23.2%, ViR = 27.3%, ViMAC= 40%, p = 0.36) after ViV and ViR compared to ViMAC. TMVI represents a reasonable treatment option in selected patients with MAC or who are poor candidates for redo mitral valve surgery. Technical success and survival up to 1 year were not significantly dependent on the subgroup in which TMVI was performed.

Ten-Year Experience with a Transapical Approach for Transcatheter Aortic and Mitral Valve Implantation.

The transfemoral approach represents the optimal access for TAVI due to its low invasiveness; however, up to 10-15% of TAVI candidates are considered unsuitable for femoral access because of significant peripheral vascular disease and need alternative access. This is a single-center retrospective observational study including all consecutive adult patients undergoing transcatheter procedures through a TA approach from March 2015 to April 2024. 213 patients underwent transcatheter aortic or mitral valve implantation through a TA approach and were enrolled in this study. The mean age of the patients was 79.5 ± 5.7 years, and 54% of the patients were males. The mean Euroscore II was 7.9 ± 6.4%. One-third of the patients had previous cardiac surgery. The overall mean survival time was 5.3 ± 0.3 years. Nine (4%) patients developed infective endocarditis (IE) during the follow-up. The transapical approach for transcatheter procedures is a safe and effective procedure for patients unsuitable for TF access with low periprocedural mortality and a low rate of post-procedural complications when performed by experienced surgeons and cardiologists.

Predictive nomogram for 28-day mortality risk in mitral valve disorder patients in the intensive care unit: A comprehensive assessment from the MIMIC-III database

BackgroundMitral valve disorder (MVD) stands as the most prevalent valvular heart disease. Presently, a comprehensive clinical index to predict mortality in MVD remains elusive. The aim of our study is to construct and assess a nomogram for predicting the 28-day mortality risk of MVD patients. MethodsPatients diagnosed with MVD were identified via ICD-9 code from the MIMIC-III database. Independent risk factors were identified utilizing the LASSO method and multivariate logistic regression to construct a nomogram model aimed at predicting the 28-day mortality risk. The nomogram's performance was assessed through various metrics including the area under the curve (AUC), calibration curves, Hosmer-Lemeshow test, integrated discriminant improvement (IDI), net reclassification improvement (NRI), and decision curve analysis (DCA). ResultsThe study encompassed a total of 2771 patients diagnosed with MVD. Logistic regression analysis identified several independent risk factors: age, anion gap, creatinine, glucose, blood urea nitrogen level (BUN), urine output, systolic blood pressure (SBP), respiratory rate, saturation of peripheral oxygen (SpO2), Glasgow Coma Scale score (GCS), and metastatic cancer. These factors were found to independently influence the 28-day mortality risk among patients with MVD. The calibration curve demonstrated adequate calibration of the nomogram. Furthermore, the nomogram exhibited favorable discrimination in both the training and validation cohorts. The calculations of IDI, NRI, and DCA analyses demonstrate that the nomogram model provides a greater net benefit compared to the Simplified Acute Physiology Score II (SAPSII), Acute Physiology Score III (APSIII), and Sequential Organ Failure Assessment (SOFA) scoring systems. ConclusionThis study successfully identified independent risk factors for 28-day mortality in patients with MVD. Additionally, a nomogram model was developed to predict mortality, offering potential assistance in enhancing the prognosis for MVD patients. It's helpful in persuading patients to receive early interventional catheterization treatment, for example, transcatheter mitral valve replacement (TMVR), transcatheter mitral valve implantation (TMVI).

Early outcomes of transapical mitral valve implantation versus surgical replacement in matched elderly patients at intermediate surgical risk.

Data comparing transcatheter mitral valve implantation (TMVI) with surgical mitral valve replacement (SMVR) are lacking. This study sought to compare the 30-day Valve Academic Research Consortium (VARC)-3 device success of TMVI with that of SMVR. Matching protocol combined exact matching (sex, atrial fibrillation, previous surgical aortic valve replacement [SAVR] or coronary artery bypass grafting [CABG]), coarsened exact matching (age) and propensity score matching (body mass index, mitral valve pathology and concomitant tricuspid regurgitation). A total of 40 Tendyne TMVI and 80 SMVR patients with similar baseline characteristics were analysed (TMVI vs SMVR): age (78 years [interquartile range [{IQR} 75; 80] vs 78 years [IQR 73; 80]; p=0.8), female (60% vs 60%; p=1.0), atrial fibrillation (67.5% vs 63.7%; p=0.8), previous SAVR (12.5% vs 10.0%; p=0.8), previous CABG (20.0% vs 16.2%; p=0.8), body mass index (25.54 kg/m² vs 25.24 kg/m²; p=0.7) and valve pathology (mitral regurgitation: 70.0% vs 73.8%, mitral stenosis: 7.5% vs 3.8%, and mixed disease: 22.5% vs 22.5%; p=0.6). Most baseline characteristics not included in the matching model were balanced among the TMVI/SMVR cohorts: European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (5.8% [IQR 2.9; 7.5] vs 4.2% [IQR 2.4; 6.8]; p=0.3) and Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score (5.2% [IQR 3.2; 8.6] vs 4.1% [IQR 3.3; 6.1]; p=0.076). Coronary artery disease (67.5% vs 32.5%; p<0.001) and previous percutaneous coronary intervention (47.5% vs 25.0%; p=0.023) differed among groups. Mitral VARC (MVARC) device success at 30 days was achieved in 82.5% of patients after TMVI and 57.5% of patients after SMVR (p=0.04). MVARC procedural success at 30 days was 75.0% after TMVI versus 52.5% after SMVR (p=0.07). Thirty-day mortality (2.5% vs 3.8%; p=0.47), technical success (97.5% vs 97.5%; p=1.0), major bleeding (17.5% vs 18.7%; p=0.087), stroke (5.0% vs 4.9%; p=1.0) and postoperative haemodialysis (7.5% vs 5.2%; p=0.4) were similar in both groups. Patients with intermediate surgical risk, according to STS-PROM and EuroSCORE II, demonstrated higher rates of MVARC device at 30 days after TMVI compared to 30 days after SMVR. Rates of survival and procedural success, neurological, renal and bleeding complications were similar. Transfusion count and length of stay were lower after TMVI. For elderly patients at intermediate risk, a TMVI eligibility assessment may be considered.

Comparison of direct oral anticoagulants and vitamin-K antagonists after transcatheter mitral valve implantation

Comparison of direct oral anticoagulants and vitamin-K antagonists after transcatheter mitral valve implantation

Emergent transcatheter mitral valve implantation: Early and mid-term outcomes

Emergent transcatheter mitral valve implantation: Early and mid-term outcomes

Comparison of direct oral anticoagulants and vitamin-k antagonists after transcatheter mitral valve implantation

Abstract Background No recommendation exists regarding antithrombotic treatment after transcatheter mitral valve implantation (TMVI). By analogy with surgical mitral bioprosthesis, vitamin-k antagonists (VKA) are mostly used after TMVI. Purpose To compare, in a prospective cohort of trans-septal TMVI using a prosthesis of the SAPIEN family, the bleeding and thrombotic risks according to the anticoagulant treatment by direct oral anticoagulants (DOAC) or VKA. Methods We included all consecutive patients undergoing trans-septal TMVI in our center from March 2011 to August 2022. Patients were followed up after the procedure at 1 month, 6 months and 1 year. The primary endpoint was the occurrence of bleeding under anticoagulant treatment. Patients were treated with VKA until October 2019 and with DOAC thereafter. Results A total of 145 patients were included. The mean age was 65.4 ± 18.6 years old and 96 patients (66.2%) were women. The mean EuroSCORE II was 10.3 ± 9,3 %. Regarding treatment, 24 patients were treated with DOAC and 121 patients with VKA. The occurrence of the primary endpoint was observed in 48 (40%) patients in the VKA group and 2 (8%) patients in the DOAC group (multivariate HR 0.21, 95%CI [0.05-0.97], p=0.047). In multivariate analysis, there were less vascular complications and stay duration was shorter in the DOAC group. There were no significant differences between groups regarding thromboembolic events, stroke, and death. Conclusion Treatment with DOAC after TMVI compared with VKA appears to decrease the risk of bleeding complications and to decrease the length of stay of patients without a significant increase in the risk of thromboembolic events.

Septal Bipolar Ablation to Prevent Left Ventricular Outflow Tract Obstruction After Transcatheter Mitral Valve Implantation.

Septal Bipolar Ablation to Prevent Left Ventricular Outflow Tract Obstruction After Transcatheter Mitral Valve Implantation.

Transapical transcatheter mitral valve implantation with J-valve in patients with degenerated mitral bioprostheses

BackgroundDue to the widespread application of bioprosthetic valve in the treatment of mitral valve disease in recent years, the incidence of valve failure has increased significantly, which is facing the need of reoperation. For high-risk patients, transcatheter mitral valve-in-valve placement is increasingly being used as an alternative to surgical reoperation.Case presentationHere we report the successful transapical transcatheter mitral valve-in-valve implantations of J-Valves in 3 patients with high risk of mitral bioprostheses failure. All patients were discharged successfully, and the follow-up results were good 30 days after operation without major complication.ConclusionsFor high-risk patients, transcatheter implantation of the J-valve is a feasible solution for the treatment of degenerated mitral bioprostheses.

Anatomic suitability for transapical transcatheter mitral valve implantation using a tether-based device.

Transcatheter mitral valve implantation (TMVI) is a novel therapeutic option for treating symptomatic mitral valve disease. Evaluating patient anatomical suitability is a critical step in the TMVI screening process, but currently requires specialized software and computerized device models. This analysis sought to assess the effectiveness of simple and standardized multislice computed tomography (MSCT) anatomic measurements for their ability to discriminate between patients who passed anatomical screening for Tendyne™ TMVI. Subjects screened for the Tendyne Expanded Clinical Study from January 2016 through September 2019 were included. Core laboratory screening measurements included mitral annular (MA) dimensions at end-systole and end-diastole, simulated device implantation, and neo-left ventricular outflow tract (LVOT) area. Additionally, nine standard measurements of patient anatomy were assessed for their predictive value of patients passing the anatomic screening process. Out of 496 subjects screened for eligibility, 257 subjects met clinical eligibility criteria with MA dimensions within the manufacturer's suggested range: 153 (59.5%) underwent TMVI while 104 (40.5%) were excluded from the study for other anatomic reasons (76% due to risk of LVOT obstruction). CT-derived left ventricular end-systole diameter (LVESD) had the highest discriminatory power for predicting TMVI anatomical suitability (area under the curve of 0.908, p < 0.0001). The mitral inter-commissural (IC) dimension was best predictive of annular dimensions being within range, with dimensions <30 or >50 mm resulting in a negative predictive value of 94.4%. MSCT-derived mitral IC dimension and LVESD easily performed measures that are effective predictors of anatomical suitability or screen failure for this tether-based TMVI device.

Evaluation of the impact of transmitral mean gradient elevation after transcatheter mitral valve implantation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Transcatheter mitral valve implantation (TMVI) has emerged as an alternative to surgery in high risk patients with failing mitral bioprosthesis (valve-in-valve) or annuloplasties (valve-in-ring). The presence of an elevated mean gradient &amp;gt; 5mmHg after the procedure has been defined as an unsuccessful procedure but the impact and outcomes of an elevated mean gradient after TMVI have not been studied. Materials and methods 103 patients undergoing TMVI from 2010 to 2020 were included. Patients were classified in three groups according to mean gradient after the procedure: Group 1&amp;lt; 5mmHg, Group 2 between 5 and 10mmHg and Group 3 &amp;gt; 10mmHg. Results The median age was 71 (52.5–81.5) years. Indications for TMVI were bioprosthesis failure in 67 patients (65%) and ring annuloplasty failure in 36 patients (35%). 84 (81.6%) patients were in NYHA class III or IV. 42 patients were in group 1, 51 in group 2 and 10 in group 3, without any difference in baseline characteristics or procedural findings. At 30 days, the rates of all-cause mortality (respectively 2,6%, 0% and 0%, p = 0,66), rehospitalization for heart failure (respectively 8,4%, 7,7% and 8,4%, p = 0,89), paravalvular leak (10,3%, 27,7%, 22,2%, p = 0,33), LVOT obstruction (respectively 6,3%, 8,2% and 10%, p = 0,99) or valve thrombosis (respectively 7,7%, 4,3% and 0%) were similar in the three groups. At a median follow up of 2 years, 27 patients have died with a cumulative rate of all-cause mortality at 1 and 2 years of 21.5% and 38.1% respectively. The presence of an elevated mean gradient was not associated with increased risk of mortality (HR=1,11, (95% CI [0,93, 1,31]), p = 0,25) An improvement of NYHA class was observed in the three groups without any difference between the groups. Median systolic pulmonary arterial pressure significantly improved in group 1 (from 53mmHg (30–90) in baseline to 45mmHg (25–60), p = 0.005) and 2 (from 55mmHg (30–112) in baseline to 40mmHg (30–75), p = 0.004)) but not in group 3. Conclusion An elevated mean gradient post-TMVI had no impact on cardiovascular outcomes up to 2 years. Further studies with longer follow up are necessary.

Timing of the narrowest neoLVOT with trans-catheter mitral valve implantation, a cardiac computed tomography study

Abstract Funding Acknowledgements Type of funding sources: None. Background Trans-catheter mitral valve replacement (TMVR) procedures had emerged as an alternative solution for patients who have surgical high risk for mitral valve surgery. One of the main challenges faced during the percutaneous approach is the degree of left ventricular outflow tract (LVOT) narrowing after implanting the new percutaneous mitral prosthesis. The remaining LVOT area (NeoLVOT) can be estimated by a commercially available CT analysis software that allows the insertion of a virtual valve within the CT dataset in the native annulus and/or the degenerated bioproshesis and hence allows measurement of the NeoLVOT using the multi-planar reconstruction (MPR) mode. The systolic phase that shows the narrowest NeoLVOT is not fully understood, and hence there is a considerable variability between operators in choosing the best phase in systole at which they should insert the virtual valve within the mitral annulus in the CT dataset to measure the narrowest NeoLVOT. Purpose To detect the systolic phase that shows the narrowest NeoLVOT and hence standardize the way to use the software to decrease variability among operators. Methods A retrospective observational single center study, including 20 patients (age 62± 4 years, 70% men), who had undergone a clinically indicated cardiac computed tomography (CT). All these patients were in sinus rhythm, had no significant coronary artery disease bases on CT report, and had normal left ventricular systolic function with no regional wall motion abnormalities, we excluded patients who had previous cardiac surgeries, hypertrophic cardiomyopathy, significant pulmonary hypertension or congenital heart disease that may affect septal motion. CTs were performed using a 128 slice dual-source (Somatom Definition Flash, Siemens Healthineers, Erlangen, Germany) with a retrospective ECG-gated acquisition CT analysis was done by a single operator using the commercially available software (3mensio Structural Heart 10.3, Pie Medical Imaging, The Netherlands). Multiphase scans were used and mid-diastole (80%), early-systole (10%), mid-systole (20%), late-systole (30–40%) were identified and analysed. Measurements done were; mitral annulus (MA) antero-posterior (AP) diameter, inter-commissural (IC) diameter, annulus area (Area), annulus perimeter (Peri), aorto-mitral angel, and the NeoLVOT area. (Figure 1). Results All measurements were feasible in all phases for all patients. The neoLVOT area was significantly narrower at end-systole (224 ± 62mm²), compared to early-systole (299 ± 70mm²) &amp; mid-systole (261 ± 75 mm²), (p = 0.005). All other measurement did not show statistically significant changes despite taking certain trends. (Figure 2). Conclusions End-systole is the cardiac phase that shows the narrowest predicted Neo-LVOT area and hence it should be the standard phase to be used during CT analysis before TMVR to predict the narrowest NeoLVOT.

Transapical Transcatheter Mitral Valve Implantation with the Tendyne Valve: The Swiss Experience.

The aim of this study was to report outcomes of all patients undergoing transcatheter mitral valve implantation with the Tendyne Mitral Valve System (Tendyne) in Switzerland. We retrospectively analyzed preoperative echocardiographic and computed tomography (CT) data, procedural findings, and 30-day and 1-year follow-up echocardiographic and clinical data of patients who underwent transcatheter mitral valve implantation with Tendyne in Switzerland. A total of 24 patients (age, 74.8 ± 7.8 years; 67% male) underwent transapical transcatheter mitral valve implantation with Tendyne between June 2020 and October 2022. Technical success rate was 96%. In five patients, concomitant interventions in the form of transcatheter aortic valve implantation (one patient), minimally invasive direct coronary artery bypass (one patient), and transcatheter edge-to-edge repair (three patients) were performed prior to or after the index procedure. There was one device embolization, and two patients required valve retrieval. In-hospital outcomes included one stroke and three major bleeding events. None of the patients died within 30 days. Two patients were rehospitalized for decompensated heart failure. At 1-year follow-up, there were three noncardiovascular-related deaths. Transcatheter mitral valve implantation with Tendyne is feasible to treat polymorbid patients suffering from complex mitral valve disease as well as patients with previous mitral interventions. Perioperative risk was acceptable and procedural success high.

Multimodal imaging assessment of mitral valve area after transcatheter mitral valve implantation: A three-dimensional echocardiographic and CT scan study

The assessment of mitral bioprosthetic area remains a technical challenge, and its calculation by the continuity equation using transthoracic echocardiography (TTE) may be invalidated in several situations, especially after transcatheter mitral valve implantation (TMVI). This study aims to develop a new technique to measure the mitral valve area after a TMVI using a multimodal three-dimensional echocardiographic and computed tomography (CT) approach. Among the patients hospitalized for TMVI at Bichat Hospital between June 2017 and February 2021, we selected 24 who had both a transesophageal echocardiography (TEE) and a cardiac CT after TMVI and before discharge. We performed two area measurements by planimetry: the geometric orifice area (GOA) corresponding to the area delimited by the edges of the open valve leaflets after alignment in the plane of the proximal coaptation point of the bioprosthesis leaflets; and the smallest valve area (SVA) defined by the smallest measurable area of the open prosthesis, at the free edges of the leaflets. In our cohort, the GOA was 1.73 ± 0.41 cm2 on 3D TEE and 1.75 ± 0.42 cm2 on CT. The SVA was 1.40 ± 0.31 cm2 on 3D TEE and 1.49 ± 0.37 cm2 on CT. There was a good agreement between the two techniques for GOA and SVA (ICC > 0.6, P < 0.01) and a good correlation between the two measurements on 3D TEE as well as on CT (Pearson 0.88 and 0.91 respectively, P < 0.001). Our work suggests a new approach to multimodal assessment of prosthetic mitral valve area after TMVI, using 3D TEE and CT scan. Further studies are needed to complete our results, especially to confirm the feasibility and reproducibility of the measurements. It would also be interesting to correlate these area measurements with the clinical prognosis of patients after TMVI. Agreement between 3D TEE and CT measurements (Fig. 1).

Emergent transcatheter mitral valve implantation: Early and mid-term outcomes

BackgroundTranscatheter mitral valve implantation (TMVI) may be attractive to treat high-risk patients with mitral bioprosthesis or annuloplasty ring failure or severe mitral annular calcification. AimTo report the outcomes of patients after valve-in-valve/ring/mitral annular calcification TMVI using balloon expandable transcatheter aortic valves, according to the degree of urgency of the procedure. MethodsAll patients who underwent TMVI in our centre from 2010 to 2021 were classified into three groups: elective, urgent or emergent/salvage TMVI. ResultsA total of 157 patients were included: 129 (82.2%) had elective, 21 (13.4%) urgent and 7 (4.4%) had emergent/salvage TMVI. Patients with emergent/salvage TMVI had a higher EuroSCORE II: elective, 7.3%; urgent, 9.7%; emergent/salvage, 54.5% (P<0.0001). The indication for TMVI was bioprosthesis failure in all of the emergent/salvage group, in 13 of the urgent group (61.9%) and in 62 of the elective group (48.1%). Overall, the technical success rate of TMVI was 86%, and was similar in the three groups (elective, 86.1%; urgent, 95.2%; emergent/salvage, 71.4%). The cumulative survival rate at 2-year follow-up was lower in the emergent/salvage group than in the elective or urgent group (42.9% vs 71.2% for the elective group; 76.2% for the urgent group; log-rank test, P=0.012). The excess mortality in the emergent/salvage group occurred during the first month postprocedure. Thereafter, the 30-day landmark analysis did not show any more statistical difference between the three groups (log-rank test, P=0.94). ConclusionsEmergent/salvage TMVI was associated with high early mortality, but 1-month survivors had similar outcomes to patients with elective/urgent TMVI. The degree of urgency of the procedure should not prevent TMVI in high-risk patients.

Valve-in-valve/valve-in-ring transcatheter mitral valve implantation vs. redo surgical mitral valve replacement for patients with failed bioprosthetic valves or annuloplasty rings: A systematic review and meta-analysis

BackgroundValve-in-valve (ViV)/valve-in-ring (ViR) transcatheter mitral valve implantation (TMVI) is a less invasive alternative to redo surgical mitral valve replacement (SMVR). To further verify its feasibility, we aimed to appraise early clinical outcomes after either ViV/ViR TMVI or redo SMVR for failed bioprosthetic valves or annuloplasty rings, as a comparison of long-term follow-up results are not available for these procedures. MethodsWe systematically searched PubMed, Cochrane Controlled Trials Register, EMBASE, and Web of Science to identify studies that compared ViV/ViR TMVI and redo SMVR. Fixed- and random-effects meta-analyses were used to compare the early clinical results between these two groups. ResultsA total of 3,890 studies published from 2015 to 2022 were searched, and ten articles comprising 7,643 patients (ViV/ViR TMVI, 1,719 patients; redo SMVR, 5,924 patients) were included. In this meta-analysis, ViV/ViR TMVI significantly improved in-hospital mortality (fixed-effects model: odds ratio [OR], 0.72; 95% confidence interval [CI], 0.57–0.92; P = 0.008) and for the matched populations (fixed-effects model: OR, 0.42; 95% CI, 0.29–0.61; P < 0.00001). ViV/ViR TMVI also outperformed redo SMVR in 30-day mortality and in rates of early postoperative complications. ViV/ViR TMVI resulted in less time spent in the ICU and hospital, whereas it showed no significant difference in one-year mortality. A lack of comparison of long-term clinical outcomes and postoperative echocardiographic results are important limitations of our results. ConclusionsViV/ViR TMVI is a reliable alternative to redo SMVR for failed bioprosthetic valves or annuloplasty rings as a result of lower in-hospital mortality, higher 30-day survival, and lower early postoperative complication rates, although there is no significant difference in 1-year mortality.

PO-01-043 CHALLENGING CASE OF LEFT ATRIAL APPENDAGE OCCLUSION AFTER TRANSCATHETER MITRAL VALVE IMPLANTATION WITH TENDYNE MITRAL VALVE SYSTEM

Left atrial appendage occlusion (LAAO) is an alternative to reduce stroke risk in patients who are poor oral anticoagulant candidates. The Tendyne (Abbott Structural, Santa Clara, CA) transcatheter mitral valve implantation (TMVI) system consists of two self-expanding nitinol frames and a trileaflet porcine pericardial valve anchored to epicardial pad by a tether. The prominent atrial cuff of the device anchors the MV, and reduces paravalvular leak but can partially obstruct the LAA ostium making LAAO challenging We describe a case of left atrial appendage occlusion using a Watchman FLX in a patient who underwent TMVI with a Tendyne mitral valve system N/A 78-year-old woman with atrial fibrillation and TMVI with Tendyne was referred for LAAO due to recurrent bleeding. Transesophageal echocardiogram (TEE) showed a Tendyne prosthesis with the outer frame overlying the os of the left atrial appendage with a small residual elliptical opening. Computed Tomography (CT) showed partial obstruction of the LAA ostium by struts from the bioprosthetic mitral valve and a 9 x 8 mm gap permitting access to the LAA. Implantation of a single lobe device (Watchman FLX) into the left atrial appendage behind the prosthetic valve apparatus was planned to completely occlude the LAA. After transeptal puncture, a fixed single curve access sheath was introduced in the left atrium. Due to partial obstruction of the LAA ostium by the Tendyne, LAA access was challenging. With TEE guidance, a pigtail catheter was placed along the limbus side of the LAA and a glidewire was then successfully advanced into the LAA through the gap in the ostium. The angiogram showed communication of LAA with the left atrium despite partial obstruction by the Tendyne. The single curve access sheath was then advanced over the pigtail catheter past the Tendyne into the LAA and a 27 mm Watchman FLX device was deployed. In the final position the device was seated entirely behind the Tendyne valve apparatus at the level of the ostium in a stable position with no evidence of residual blood flow. Post watchman device placement, there was no damage or movement of the valve apparatus and no exacerbation of mitral regurgitation. The atrial cuff of the transcatheter mitral valve system can encroach on the LAA ostium and make LAAO challenging. Careful preoperative planning using CT can guide device selection and help mitigate challenges.