A Case of Multivalvular Heart

Disease

Sahil Khera MD, MPH

Structural Heart and Valve Fellow

Columbia University Medical Center

Clinical Background

• 80 year old lady with h/o HTN, HLD, Afib, NHL in

remission, RCC s/p left nephrectomy

• 27mm Edwards Magna MVR, TV ring 2012

• True Stent ID: 26mm

• High-Prohibitive STS

• Multiple readmissions for Acute Decompensated

HF

• Now NYHA IV dyspnea, LE edema, JVD

• IV diuretics

• EF 77%, serum Cr 1.09, INR 1.3, Hgb 11 , Platelets

167

Aortic Valve

MVR Appearance On Fluoroscopy and CT

27mm MV Magna Valve-in-Valve App

Mitral Valve

Arterial Access

Severe AS – MG 39mmHg, Vmax

4.0m/s, AVA 0.8cm2

Severe MS – MG 11mmHg, MVA

(planimetry) 1.0cm2

MVR post in LVOT, NeoLVOT

169mm2 on CT

LVH with small cavity – EF 77%

LCA height 11mm, SOV 25-

28mm, Leaflet length 12.8mm

Concept of neo-LVOT

Blanke et al JACC Imaging 2017

Anatomical and Device Related Factors Predisposing to Narrow the Neo-LVOT

Dimension

A parallel orientation is

associated with a lower risk of

LVOT obstruction, and a

perpendicular orientation

conferring the highest risk.

LM protection ?

Feasibility of TMVR ?

Role of Embolic Protection?

Plan:

TAVR with 23mm S3 with LCA

protection

TMVR with 29mm S3 with KB

in LVOT

Bailout ASA if required

Sentinel Device

Placed via 6F RRA

LCA Angiogram

BMW wired subsequently placed into LAD

BAV with LCA Injection

22mm Z-NuMed balloon

23mm S3

S3 popped up during deployment and then unable

to advance beyond MVR annular stent in aorto-

mitral curtain location

Good LCA Flow Post TAVR

Post BAV

Mild PVL to no PVL with BAV

Assessment for LVOTO

No Significant LVOT Gradient

Post Trans-Septal

TS with Baylis sheath. Exchanged for 8.5F Agilis sheath

Mean Trans-Mitral Gradient 12mmHg

MV Crossing

8.5F Agilis sheath, straight wire and MPA. MPA

used to exchange for Confida wire.

Septal Dilatation

12 x 40mm balloon

29mm S3 with 22mm LVOT-KB

29mm S3 TMVR with deployed with 2ml extra (35ml) and

22mm NuMed LVOT balloon to tilt C3 away from LVOT

Final Result

Final Result

Final Trans Mitral PG 3mmHg

Final LVOT PG 8mmHg

LFA Closure