Transesophageal guidance for trans-catheter trans-septal mitral valve in valve implantation

Abstract

Introduction In patients with high surgical risks, transcatheter mitral valve-in-valve replacement (VIV-TMVR) offers a less invasive alternative to open surgical approach for failing mitral bioprosthetic valves (1). Valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) in failing aortic valve bioprosthesis is already an established technique worldwide (2). Transesophageal echocardiography (TEE) plays a vital role in the intraoperative management of these cases. Here we describe the approach to TEE evaluation and guidance of VIV-TMVR. Methods TEE is used for full assessment of the heart pre-procedurally as well as throughout the procedure to guide the placement of the new mitral valve and at the end to assess the integrity of the placement and to detect any complications.Both 2D B and color doppler modes as well as real-time, zoom and full volume 3D TEE modalities can be used to serve different purposes. Results Successful placement of an Edward Sapien S3 Valve (29 mm) under TEE guidance Discussion Pre-procedurally, severity and etiology of the bioprosthetic mitral valve disease should be confirmed using TEE (Fig 1A) as well as identification of factors that would contraindicate a VIV-TMVR such as infective endocarditis, severe paravalvular leak, bioprosthetic valve dehiscence or significant prosthesis-patient mismatch. It is also imperative to complete a baseline assessment of the right and left ventricular size and function, left atrial size and look for any pericardial effusion. During the procedure, TEE may rarely be used for guidewire placement into the IVC by the interventional cardiologists. Next, a combination of bicaval (90-110°) and aortic short axis (30-45°) views are used to guide the cardiologist to puncture the interatrial septum. The ideal site for puncture in these cases is determined in mid systole to be posterior and superior on the septum about 3-4 cm above the mitral annular plane. (Fig 1B) The puncture and passing of guidewire into the left atrium is followed by the passing of the valve deployment system, all of which are easily visible on TEE toggling between 2D and live 3D modes. (Fig 1C,D&E) Post-deployment TEE assessment include confirmation of the stability of the new valve as well as ensuring leaflets are moving freely with no or minimal mitral regurgitation, no paravalvular leaks and no flow restriction across the valve. (Fig 1F) The size, severity and directionality of the interatrial shunt created by the iatrogenic atrial septal puncture site should be assessed using color and spectral doppler, (Figure 1G) which may require placement of an Amplatzer ASD percutaneous closure device (Figure 1H).