Echocardiographic guidance and monitoring of transcatheter mitral valve replacement in severe mitral annular calcification and failing bioprostheses; mid-term follow-up data are encouraging: P1-121
Harland D, O'Hair D, Bajwa TK, Allaqaband SQ, Khandheria BK, Kirby A, Jain R . Echocardiographic guidance and monitoring of transcatheter mitral valve replacement in severe mitral annular calcification and failing bioprostheses; mid-term follow-up data are encouraging: P1-121. Journal of the American Society of Echocardiography, 2017;30(6), B52-B53.
Poster presented at: 2017 ASE 27th Annual Scientific Sessions, June 2-6, 2017; Baltimore, MD.
Background: Transcatheter mitral valve replacement (TMVR) with an Edwards Sapien XT valve has emerged to treat high-risk patients with severe mitral calcific stenosis or failing bioprostheses, yet limited data are available on outcomes beyond one year. Echocardiography is used to both intraprocedurally guide placement of TMVR and to follow prosthesis function.
Methods: We evaluated clinical and echocardiographic variables of patients who received TMVR at our institution.
Results: Baseline characteristics of 9 patients are listed in the Table. All patients were deemed extreme risk by our Heart Team; TMVR was performed via transapical approach (n=8) or redo sternotomy (n=1). TMVR sizing was based on computed tomography angiography (26 mm [n=5], 29 mm [n=4]). All were placed on cardiopulmonary bypass for a brief period during deployment (3-9 mins) while transesophageal echocardiography was used to ensure proper seating of the valve and to minimize impingement of the left ventricular outflow tract (LVOT) by the valve stent. Complications included tamponade aft er deployment (n=1) requiring pericardial window, moderate paravalvular regurgitation (PVL) (n=1) treated with vascular plug, non-debilitating stroke 24 hours post deployment (n=1), and asymptomatic dynamic LVOT obstruction (n=1). One patient died 72 hours after combined TMVR/transcatheter aortic valve replacement from mesenteric ischemia, but the remaining 8 patients are alive with symptom improvement, mitral mean gradient 5.8 mmHg±3.02 mmHg, decreased pulmonary artery systolic pressure (PASP) (49.6±13.1 mmHg), and ≤ mild PVL. At mean follow-up of 15.5 months (range 4-26), there was a slight increase in the mean mitral valve gradient (mean increase 2.35±1.8) from the immediate postprocedure echocardiogram, but no change in regurgitation. Four patients with >1 year follow-up are clinically doing well.
Conclusion: TMVR is associated with favorable short- and mid-term outcomes. Transesophageal echocardiography performed during the procedure is essential for minimization of complications, and when performed during cardiopulmonary bypass, allows for adequate time to optimize stent depth. Follow-up beyond 1 year suggests stable mitral prosthetic valve function without echocardiographic or clinical evidence of degeneration.