A rare case of valve in valve mitral valve replacement: challenges for a cardiac anesthesiologist!

ABSTRACT

Transcatheter mitral valve replacement (TMVR) has revolutionized care of patients with valvular heart disease. Re-do surgeries of mitral valve in high risk surgical patients with right ventricular (RV) dysfunction are associated with high morbidity and mortality. An elderly male with history of rheumatic heart disease, hypertension, chronic kidney disease;previously operated for prostatic cancer, mitral valve replacement (2008) and recently recovered from COVID infection, presented to emergency with breathlessness. He was diagnosed to have pleural effusion with severe restenosis of prosthetic valve. Degenerated, thickened, prosthetic mitral valve (peak/mean gradient-35/22), severe pulmonary hypertension (RVSP=91mmHg) with moderate RV dysfunction (TAPSE 10, RV S' 9) qualified him as high risk for redo valve surgery (STS and EURO Score), hence was posted for valve in valve TMVR (VIV TMVR). Patient was successfully managed under general anesthesia with pulmonary artery catheter and transesophageal echocardiography (TEE) monitoring to optimally guide the hemodynamics and decision to extubate in hybrid lab. TEE performed by cardiac anesthesiologist, was used to guide the most critical step of optimum puncture site on inter atrial septum (combination of mid esophageal 4 chamber, bicaval and aortic short axis view), appropriate deployment of valve (position, stability, leaflet motion, gradients, paravalvular leak, subvalvular involvement of delivery apparatus) and early diagnosis of complications (tamponade, bioprosthesis embolization, LVOT obstruction). Challenges faced by an anesthesiologist are that of non-operating room anesthesia in patients of American society of anesthesiologist grade III or more, maintaining hemodynamic stability, anticipation and early management of complications and aiding valve placement with the use of TEE. TMVR, developed initially for candidates with high risk for surgical repair, will likely replace surgical mitral valve replacement in future as technology improves and the outcomes are proved. Challenging role of a cardiac anesthesiologist to guide the procedure for a successful outcome cannot be much emphasized.