JIM Today 2018 - Saturday - page 3

Issue 3 
 24 February 2018 
JIM today
terms of sizing, everybody has their own tricks.
And the reason why I think you need to use IVUS
in these cases is that this is an LAD ostium of a
51-year-old. You have to have a result which is as
good as a surgeon putting a mammary artery in.
You have to be meticulous to make sure that the
sizing and the location of the stent are correct. So I
applaud your use of the IVUS.”
Transfemoral mitral VIV
Drs Nickenig and Werner presented a transfemoral
mitral valve-in-valve (VIV) implantation in a 75-year
old male patient with past medical history including
three-vessel CAD (now stable), paroxysmal atrial
fibrillation (CHADS-VASc score of 3) and chronic
kidney disease (eGFR 56 ml/min). Surgical history
included surgical mitral valve replacement in 2010
(with 29-mm Carpentier-Edwards SAV biopros-
thetic valve (Edwards Lifesciences, USA) of inner
diameter 28 mm), and additional CABG surgery.
The patient presented with dyspnea NYHA III.
The present procedure was carried out due to
degeneration of the previously implanted mitral
valve. The patient arrived with normal LVEF, but
with severe mitral regurgitation due to a flail leaflet
of bioprosthetic mitral valve. Coronary angiogra-
phy indicated patent grafted vessels. CT workup
allowed measurement of valve dimensions and
simulation of implantation, landing zone and left
ventricular outflow tract (LVOT) obstruction risk.
Importantly, neo-LVOT estimation suggesting
that correct implantation should not significantly
impair outflow.
The team opted for a transseptal transfemo-
ral mitral VIV using a 29-mm Sapien 3 (Edwards
Lifesciences). While 26 mm was an option, in this
particular patient the team prioritised a maximised
neo-LVOT area.
Dr Leon commented: “This is a very exciting
case, with relatively early bioprosthesis dysfunc-
tion. This is a perfect case for a balloon-expandable
transeptal VIV. We have got
more and more experience with
these. We used to do them
transapically, but we think the
transseptal approach is better.”
Commenting in general on
procedural planning in trans-
septal VIV, panel member
Alan Yeung asked: “There is a
question [about] all the angles
– each patient is quite different
because of [issues like] enlarged
left atrium. We usually try to do a 3D print of the
heart to help guide us as to where to do the trans-
septal puncture. Some cases go very smoothly, and
in some cases you struggle and struggle because of
the angles. Do you do any additional preparation
to understand the anatomy between the septum
and the mitral valve in the transseptal approach?”
Dr Nickenig replied: “It is extremely crucial
if you don’t have a visible ring, for example, in
implanting a valve-in-ring. Then you have to do a
really extreme workup upfront with CT scans and
so on. If you have a visible stent frame you can go
with fluoroscopy, you have to have a plain view of
the valve, and you have to have transoesophageal
echo (TOE) guidance at the same time.
“Back to the angle, you don’t have the freedom
to choose your angle. Sometimes the problem is
that you cannot get superior enough because you
are still in the muscular part of the atrial septum.
That was also the case here.”
On the team’s wire and catheter choice, he
continued: “You could use, for example, an IMA
catheter. You could also use a
steerable sheath, but this is usu-
ally not necessary. Right now
we have a Confida [CoreValve,
Medtronic, USA] wire sitting in
the left ventricle.”
During valve placement, Dr
Leon commented: “As you see
it almost never is truly coaxial.
As balloon expands it will begin
to right itself. I don’t want to
say ‘you have to guess’, but you
have to be aware of valve shortening issues, so you
have to be careful where you place it because of
this. How much it is going to foreshorten is hard to
say. These valves shorten from bottom to top.”
Following deployment, the team concluded by
confirming positioning and haemodynamics with
TOE and angiography. Dr Leon noted: “You can
see that the Sapien 29 is a little bit indented, and
that is because there is enough in the way of tissue
that you don’t get full expansion. You actually look
for indentation, which gives you reassurance that it
is secure in its location.”
Dr Nickenig added: “If we didn’t have any
indentation, I would be worried that it would
embolise later on.”
planning in retrograde CTO and mitral VIV
“If we didn’t have
any indentation, I
would be worried
that it would
embolise later on.”
Georg Nickenig
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