2024 FSA Podium and Poster Abstracts
P069: HEMORRHAGIC BLEEDING FOLLOWING VALVE-IN-VALVE TRANSCATHETER MITRAL VALVE REPLACEMENT
Matthew Yu, BS1; Michael Fitzpatrick, MD2; Gerald P Rosen, MD2; 1FIU Herbert Wertheim College of Medicine; 2Mount Sinai Medical Center
Bioprosthetic valves have an inherent risk of obstruction secondary to thrombus, fibrocollagenous overgrowth, or both. Post-valve replacement, exposed endothelium, and blood flow stasis favors formation of thrombus and subsequent outflow obstruction. Prosthetic valve obstruction (PVO) occurs in 0.1-6.0% of cases depending on valve type and position, anticoagulation status, and risk factors, including advanced age, hypertension, hyperlipidemia, smoking, hyperparathyroidism, diabetes mellitus, and end-stage renal disease.
The first-line treatment for left-sided PVO in severely symptomatic patients is surgical valve replacement. Studies reveal that up to 50% of bioprosthetic mitral valves degenerate within 15 years, requiring a repeat open heart surgery. High mortality rates of up to 13% with repeat surgery led to the development of valve-in-valve transcatheter mitral valve replacement (ViV-TMVR), a minimally invasive alternative for high-risk patients. ViV-TMVR has successfully treated hundreds of patients worldwide. Complications include valve embolization, left ventricular (LV) outflow tract obstruction, and damage to adjacent structures (LV perforation, LV pseudoaneurysm, mitral valve leaflet/chordal disruption, pulmonary vein perforation), which may require procedural conversion to open heart surgery.
This is a case of a 88-year-old female with medical history significant for HTN, HLD, CKD, chronic Afib, prior DVT, and status-post bioprosthetic mitral valve replacement, who succumbed to the complications of her ViV-TMVR. Prior to surgery, she endorsed progressive dyspnea on exertion, fatigue, and orthopnea due to obstruction of her bioprosthetic mitral valve. Preoperative scans revealed mild cardiomegaly, asymmetric enlargement of the left atrium, and severe bioprosthetic valve obstruction and thickened mitral leaflets with reduced motility in the setting of preserved LV ejection fraction of 60-65%.
Percutaneous access was obtained via the right common femoral vein and following a transseptal puncture, the transcatheter was advanced into the bioprosthetic mitral valve. Positioning the valve through the mitral annulus worsened the pre-existing obstruction, resulting in severe hypotension and hemodynamic instability unresponsive to significant vasopressors. A large pericardial effusion was identified and after unsuccessful pericardiocentesis, the procedure was converted to open sternotomy. After an hour of desperate efforts to relieve the cardiac injury, the patient was pronounced dead.
PVO is a common complication after valve replacement via open heart surgery. ViV-TMVR has proved to be a safe surgical alternative with lower rates of complications. The transseptal approach with TEE/fluoroscopic guidance is the most accepted given its efficacy and safety profile. Advantages include replacement of the valve without removal of the pre-existing valve, decreasing risk of injury to surrounding vessels. Major complication is left ventricular outflow tract (LVOT) obstruction – on entry of the transcatheter valve, anterior leaflet of the degenerated valve may shift towards IV septum, resulting in narrowed LVOT, hemodynamic instability, and death.
ViV-TMVR, a minimally-invasive alternative to the traditional open-heart surgery for mitral valve replacement, has gained popularity given its positive outcomes in patients with high surgical risk. This case highlights a major complication of ViV-TMVR, LV laceration resulting in hemorrhagic bleeding, and the need for further research to evaluate the long-term effects of mitral valve replacement with this novel approach.