Computer-Assisted Transcatheter Mitral Valve Implantation for Valve-in-Valve Procedures

ABSTRACT Transcatheter mitral valve-in-valve is an alternative to high-risk reoperation on a failing bioprosthesis. It entails specific challenges such as left ventricular outflow tract obstruction. We propose a patient-specific augmented imaging based on preoperative planning to assist the procedure. Valve-in-valve simulation was performed to represent the optimal level of implantation and the neo-left ventricular outflow tract. These data were combined with intraoperative images through a real-time 3D/2D registration tool. All data were collected retrospectively on one case (pre and per-procedure imaging). We present for the first time an intraoperative guidance tool in transcatheter mitral valve-in-valve procedure.

A Rare Case of Left Ventricular Outflow Tract Obstruction 18 Years after a Mechanical Mitral Valve Replacement

Background: Left ventricular outflow tract (LVOT) obstruction is a serious complication that can occur after various mitral-valves, surgical or percutaneous, interventions. It was rarely described in mechanical mitral valve replacements. Aim: to describe a rare case of late LVOT obstruction after a mitral valve replacement by a low-profile mechanical prosthesis. Case Presentation: A 48-year woman, with a history of rheumatic mitral valve disease and mechanical mitral replacement by a hemi-disc valve 18 years ago, presented for a recent dyspnea. Echocardiography showed a narrowing of the LVOT, with anterior position of the mitral prosthesis, aorto-mitral annular angulation, septal thickening and remnant native sub-valvular tissue attached to the septum in the LVOT region. This resulted in LVOT obstruction with a peak gradient of 75 mmHg. The heart team opted for a redo surgery, but the surgical decision was refused by the patient. Discussion: This is a rare case of late LVOT obstruction after mitral valve replacement by mechanical low-profile prosthesis. Preserved native mitral valve tissue, which is the main described cause of LVOT obstruction after mechanical mitral valve replacements was not the unique cause of obstruction in this patient who had also a septal thickening and anterior prosthetic position. Aorto-mitral annular angulation that was identified as a risk factor of LVOT obstruction after trans-catheter mitral valve replacements, should be, probably, also took into account and assessed pre-operatively in patients undergoing surgical mitral replacements. Conclusion: LVOT obstruction can occur after mechanical mitral replacements event with low profile prosthesis. In patients with identified risk factors of LVOT obstruction, preservation mitral anterior leaflet should be avoided, and preservation of other native mitral tissue should be discussed.

The prognosis of the complete transposition of great arterial with left ventricular outflow tract obstruction after arterial switch operation / 中华胸心血管外科杂志

Objective To analyze the clinical characteristics of complete transposition of great arterial with left ventricular outflow tract obstruction(TGA/LVOTO) patients who received arterial switch operation(ASO),and further evaluated the risk factors of postoperative adverse events.Methods Retrospectively evaluated the adverse events(including postoperative mortality,reoperation,aortic valve insufficiency,re-LVOTO and mitral valve insufficiency) and the related risk factors of 39 TGA/LVOTO patients after ASO.Results 39 TGA/LVOTO patients were included,the mean Z value of PV was 0.6,the mean peak LVOT gradient was 31.6 mmHg (1 mmHg =0.133 kPa).The mean follow up time was 15.9 months,during the follow up,1 patient had early mortality,and CPB time(P =0.034) was associated with early mortality;4 patients had early reintervention;15 patients had AVI,and larger PV Z value(P =0.026) was associated with postoperative AVI;7 patients had MVI,and subvalvar level LVOTO(P =0.001) was associated postoperative MVI;6 patients had re-LVOTO,and older age at operation (P =0.029),muhi-level LVOTO (P =0.024) were associated with postoperative re-LVOTO.Conclusion If the obstruction of LVOT can be repaired by surgery,TGA/LVOTO patients had a satisfied prognosis after ASO with relief of LVOTO,the postoperative early mortality was very low,and although the probability of re-LVOTO was increased with time,the long-term reintervention probability was very low.

Tricuspid valve straddling: An uncommon cause of left ventricular outflow tract obstruction in transposition of great artery with ventricular septal defect

Transposition of great arteries (TGA) can be associated with left ventricle outflow tract (LVOT) obstruction. In the presence of ventricular septal defect (VSD), septal leaflet of tricuspid valve may prolapse through perimembranous VSD or rarely tricuspid valve tissue may override to produce LVOT obstruction. Occasionally, this may be mistaken for vegetation due to associated pulmonary valve endocarditis. We report a case of d-TGA with presumptive pulmonary valve endocarditis and LVOT obstruction that was found to be due to tricuspid valve straddling on transesophageal echocardiography, resulting in change in the surgical plan and thus avoiding catastrophe.

Pregnancy in Hypertrophic Cardiomyopathy with Severe Left Ventricular Outflow Tract Obstruction

Hypertrophic obstructive cardiomyopathy (HOCM) patients with severe left ventricular outflow tract (LVOT) obstruction (those with a gradient of > 100 mm Hg) are at the highest risk of hemodynamic deterioration during pregnancy. Complications of HOCM include sudden cardiac death, heart failure, and arrhythmias. Physiological changes during pregnancy may induce these complications, affecting maternal and fetal health conditions. Therefore, close monitoring with appropriate management is essential for the well-being of both mother and fetus. We report on the case of a 27-year-old female patient with severe LVOT obstruction HOCM, pressure gradient (PG) of 125 mm Hg at resting, and 152 mm Hg induced by the Valsalva maneuver at 34 weeks gestation. This case showed how close monitoring using echocardiography and proper management during the course of pregnancy resulted in successful delivery in the patient with extremely high PG HOCM.

Hypertrophic cardiomyopathy: Part 1 - Introduction, pathology and pathophysiology.

Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiovascular disease with many genotype and phenotype variations. Earlier terminologies, hypertrophic obstructive cardiomyopathy and idiopathic hypertrophic sub‑aortic stenosis are no longer used to describe this entity. Patients present with or without left ventricular outflow tract (LVOT) obstruction. Resting or provocative LVOT obstruction occurs in 70% of patients and is the most common cause of heart failure. The pathology and pathophysiology of HCM includes hypertrophy of the left ventricle with or without right ventricular hypertrophy, systolic anterior motion of mitral valve, dynamic and mechanical LVOT obstruction, mitral regurgitation, diastolic dysfunction, myocardial ischemia, and fibrosis. Thorough understanding of pathology and pathophysiology is important for anesthetic and surgical management.

Implante de conducto apicoaórtico en paciente con estenosis aórtica severa post reemplazo valvular protésico / Apicoaortic valved conduit implanted in a patient with severe aortic stenosis due to mismatched aortic valve prosthesis

Introducción: La estenosis aórtica fibrocálcica es el tipo de valvulopatía más frecuente, especialmente en los adultos mayores, siendo el reemplazo valvular aórtico el tratamiento definitivo. Un mal resultado post operatorio puede deberse a un mal funcionamiento de la válvula protésica. Caso clínico: Paciente de 42 años de edad sometido a reemplazo valvular aórtico por presentar estenosis aórtica severa fibrocálcica en una válvula bicúspide y aorta de pared muy fina. Evoluciona asintomático durante 4 años, al cabo de los cuales y luego de abandonar su tratamiento anticoagulante consulta por disnea y dolor anginoso. Un ecocardiograma muestra estenosis severa de la válvula protésica. Dado los antecedentes de su cirugía previa se decide implantar un conducto de dacrón valvulado ápico-aórtico a través de toracotomía posterolateral izquierda. Evolución post operatoria muy satisfactoria permaneciendo asintomático, con un seguimiento de 15 meses. La recidiva de la estenosis aórtica severa post reemplazo valvular protésico tiene en el bypass ápico-aórtico una excelente alternativa de tratamiento efectivo, especialmente cuando el recambio valvular tradicional implica un alto riesgo quirúrgico.

Introduction: The most frequent surgical procedure of severe left ventricular outflow tract obstruction due to severe aortic stenosis is aortic valve replacement, but there is an alternative and less conventional method described by Cooley used in patients with previous aortic valve replacement and severe aortic wall calcification that bypasses the left ventricular outflow tract through the implant of an apicoaortic valved conduit. Clinical case: We describe the case of 42 years old patient with severe aortic stenosis due to mismatched valve prosthesis previously installed treated by of apicoaortic conduit implanted through left posterolateral thoracotomy.

Left Ventricular Myxoma Leading to Left Ventricular Outflow Tract Obstruction / 대한내과학회지

Cardiac myxoma is the most common primary cardiac tumor, but ventricular myxoma accounts for only 5% of the cases. We report a case of a 62-year-old woman with a left ventricular myxoma emerging from the ventricular side of the mitral valve that led to left ventricular outflow tract obstruction. The patient complained of chest discomfort and dyspnea. A mobile intracardiac mass was seen on echocardiography. The mass was excised and confirmed to be a myxoma by histopathological examination. She was discharged from the hospital without complications and remains asymptomatic.

Dynamic left ventricular outflow tract obstruction without basal septal hypertrophy, caused by catecholamine therapy and volume depletion

Hypertrophic cardiomyopathy (HCM) with hypertrophy of the basal septum is the most common etiology of left ventricular outflow tract (LVOT) obstruction. In this article, we report the case of a patient with a structurally normal heart who developed hemodynamic deterioration due to severe LVOT obstruction following treatment with catecholamines. Hypovolemia accompanied with a hyperdynamic condition, resulting from catecholamine treatment, may cause dynamic LVOT obstruction due to the systolic anterior motion of the mitral valve leaflet. The solution for this is early recognition and correction of aggravating factors such as, withdrawal of catecholamine therapy and volume replacement.

Mitral Valve Replacement to Control Recurrent Systolic Anterior Motion of Mitral Valve and Left Ventricular Outflow Tract Obstruction after Alcohol Septal Ablation

Dynamic left ventricular outflow tract (LVOT) obstruction caused by systolic anterior motion (SAM) of the mitral valve is observed in variable clinical conditions with anatomical or functional abnormalities of LVOT and mitral valve. Several treatment options to relieve obstruction have been suggested including medications to change the contractility of left ventricle, volume reduction of interventricular septum by surgical or non-surgical catheter-based intervention, and surgical correction of the abnormal mitral valve. Here we reported a case of 48-year-old man who presented with shortness of breath. After repeated alcohol septal ablation, mitral valve replacement was finally performed to achieve complete symptom relief.

A Case of Left Ventricular Outflow Obstruction Caused by Mitral Valve Replacement

The pathophysiology, clinical presentation and prognosis of left ventricular obstruction present an important cardiological problem. Various anatomical and functional abnormality can cause this phenomenon. Rarely, left ventricular outflow obstruction can result after mitral valve surgery. We experienced a case of left ventricular outflow obdtruction 13 years after mitral valve replavement. The diagnosis was made using two-dimensinal Doppler echocardiography and confirmed by cardiac catheterization. The pressure gradient across the left ventricular outflow obstruction was 96mmHg. A second mitral valve replacement was performed. Because severe fibrosis, pannis around the prosthetic mitral valve and a subaortic web were detected during the operation, the subaortic web was removes.