Advanced Procedure – Advanced Complications?

Background:

Transcatheter mitral valve replacement (TMVR) for high risk patient with failed mitral valve replacement and repair is an appealing option with acceptable outcomes.

Our case:

A 68 years old male underwent in 1999 coronary bypass surgery and mitral reconstruction with Carpentier-Edwards ring 32mm. Now he was admitted with heart failure NYHA III, severely reduced left ventricle function and high grade mitral valve regurgitation. Due to the high risk of reoperation the Heart team decided over a TMVR. Under general anesthesia the procedure was performed from femoral vein and trans-septal approach. After implantation of an Edwards Sapien 3 29mm valve under rapid pacing, blood pressure did not recover. Echocardiography revealed the valve implanted in the opposite orientation (Figure 1). With minimal dose of adrenaline and partial inflation of the balloon of the Edwards valve the patient maintained minimal circulation. A second valve was implanted in the first valve, in the correct orientation (Figure 2) with minimal para-valvular regurgitation. The patient returned to conscious in the operating room with no overt neurological deficit.

Discussion:

While preparing the valve, it was at first oriented correctly but fell of the system during crimping and then reloaded wrongly. Quality control by the operators might have prevented actual implantation in the wrong orientation. Partial inflation of the balloon allowed some blood flow from the left atrium to the ventricle and maintained perfusion.

Conclusions:

Mutual control by the operating team, especially in unusual procedures is essential. Rapid reaction can prevent fatal results after complications.