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Innovative Solutions to an Old Problem: Valve in Valve Procedures for Mitral Valve Re-Stenosis After Rheumatic Heart Disease
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A3436 - Innovative Solutions to an Old Problem: Valve in Valve Procedures for Mitral Valve Re-Stenosis After Rheumatic Heart Disease
Author Block: J. Lozier; Internal Medicine, University of Connecticut, Farmington, CT, United States.
The patient is a 56 yo Hispanic F with hx of rheumatic mitral valve disease with mitral stenosis and mitral regurgitation complicated by by pulmonary hypertension, CHF, and atrial fibrillation. She had a mitral valve replacement in 4/2008 with #27 Perimount bioprosthetic valve and LA appendage occlusion and maze procedure. She has had worsening DOE and multiple CHF exacerbation presentation over the proceeding year and presented again in July with NYHA class IV heart failure symptoms. Her other comorbid conditions include Sjogren's Syndrome on chronic steroids, ILD on 4-6L NC O2 at baseline, OSA on CPAP, paroxysmal atrial fibrillation (CHADS-VASC 5) on coumadin, DMT2, HTN, HLD, morbid obesity with BMI 46, and CKD. She was dieuresed aggressively during her stay until she was 14L net negative, her renal function had returned to baseline, and she returned to her dry clinic weight. Unfortunately she continued to be very short of breath with mini mal activity. Ultrasonography of her heart demonstrated progression of her mitral valve disease to severe restenosis. MV gradient was noted to be 12 (increased from 8 in 3 months earlier, T1/2p now 158, MVA 1.4cm2, compared to recent echo 3 months prior that showed MV p 1/2t 123, mean gradient 8, and MV area 1.8 cm2. Decision was made to pursue valve replacement options. She was evaluated by cardiothoracic surgery for open replacement and deemed an extremely high risk candidate with baseline STS mortality of 7.4%. Decision was made to pursue a valve-in valve percutaneous trans aortic mitral valve replacement with 26 mm Edwards S3 valve. Following implantation of the 26 mm S3 valve, mean mitral valve gradient decreased from 10 mmHg to 3 mmHg with a decrease in mean left atrial pressure from 35 mmHg to 25 mmHg. Transesophageal echocardiography demonstrated trace paravalvular mitral regurgitation. Cardiac fluoroscopy demonstrated excellent placement of the S3 prosthesis within the 27 mm Perimount valve. Pt will be anti coagulated with coumadin for the rest of her life.
Author Block: J. Lozier; Internal Medicine, University of Connecticut, Farmington, CT, United States.
The patient is a 56 yo Hispanic F with hx of rheumatic mitral valve disease with mitral stenosis and mitral regurgitation complicated by by pulmonary hypertension, CHF, and atrial fibrillation. She had a mitral valve replacement in 4/2008 with #27 Perimount bioprosthetic valve and LA appendage occlusion and maze procedure. She has had worsening DOE and multiple CHF exacerbation presentation over the proceeding year and presented again in July with NYHA class IV heart failure symptoms. Her other comorbid conditions include Sjogren's Syndrome on chronic steroids, ILD on 4-6L NC O2 at baseline, OSA on CPAP, paroxysmal atrial fibrillation (CHADS-VASC 5) on coumadin, DMT2, HTN, HLD, morbid obesity with BMI 46, and CKD. She was dieuresed aggressively during her stay until she was 14L net negative, her renal function had returned to baseline, and she returned to her dry clinic weight. Unfortunately she continued to be very short of breath with mini mal activity. Ultrasonography of her heart demonstrated progression of her mitral valve disease to severe restenosis. MV gradient was noted to be 12 (increased from 8 in 3 months earlier, T1/2p now 158, MVA 1.4cm2, compared to recent echo 3 months prior that showed MV p 1/2t 123, mean gradient 8, and MV area 1.8 cm2. Decision was made to pursue valve replacement options. She was evaluated by cardiothoracic surgery for open replacement and deemed an extremely high risk candidate with baseline STS mortality of 7.4%. Decision was made to pursue a valve-in valve percutaneous trans aortic mitral valve replacement with 26 mm Edwards S3 valve. Following implantation of the 26 mm S3 valve, mean mitral valve gradient decreased from 10 mmHg to 3 mmHg with a decrease in mean left atrial pressure from 35 mmHg to 25 mmHg. Transesophageal echocardiography demonstrated trace paravalvular mitral regurgitation. Cardiac fluoroscopy demonstrated excellent placement of the S3 prosthesis within the 27 mm Perimount valve. Pt will be anti coagulated with coumadin for the rest of her life.
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