Long or redundant leaflet complicating transcatheter mitral valve replacement: Case vignettes that advocate for removal or reduction of the anterior mitral leaflet

Abstract

Transcatheter mitral valve replacement (TMVR) procedures can be an alternative to surgical valve replacement for high surgical risk patients with bioprosthetic mitral valves, annuloplasty rings, or severe mitral annular calcification (MAC). TMVR can trigger acute left ventricular outflow tract (LVOT) obstruction from permanent displacement of the native anterior mitral leaflet toward the left ventricular septum, more often among patients undergoing valve-in-ring and valve-in-MAC procedures. Although acute LVOT obstruction is well described in the literature, there are important additional complications of TMVR related to the length and/or redundancy of the anterior mitral valve that have been recognized after mitral valve surgery and have not been previously reported in the setting of TMVR. These additional complications include acute mitral regurgitation secondary to prolapsing native leaflet through the TMVR, frozen TMVR leaflet secondary to overhanging native leaflet and late LVOT obstruction in the neo-LVOT secondary to long native leaflet. Preprocedural planning with imaging (echocardiography and computed tomography) and measurement of anterior mitral leaflet length is critical important in understanding the risk for these complications. As transcatheter mitral valve technology proliferates, interactions with the anterior mitral leaflet after TMVR may be more frequent than initially anticipated. We believe that there is no advantage to an intact anterior leaflet and advocate removal or reduction of the leaflet prior to TMVR. © 2017 Wiley Periodicals, Inc.

Keywords: complications; redundant anterior leaflet; transcatheter mitral valve replacement; valve-in-MAC; valve-in-native; valve-in-ring; valve-in-valve.

Fig. 1

Transcatheter mitral valve-in ring. A: A 26-mm Edwards Sapien valve was deployed at the level of the mitral valve ring using a transapical approach. B: Intraoperative transesophageal echocardiogram (TEE) after mitral valve-in-ring replacement revealed native valve leaflets (blue arrow) overhanging and interfering (C) with closure of the prosthetic leaflets (white arrow), and resulting severe central MR (D) by color Doppler (arrow). D: A 22-mm Melody valve was deployed farther into the atrium away from the prolapsing leaflet. E: TEE after second transcatheter valve showing functioning transcatheter valve leaflets (white arrow) that are a significant distance from native valve leaflets (white arrow). [Color figure can be viewed at wileyonlinelibrary.com]

Fig. 2

A: A 23-mm Edwards Sapien S3 valve (Edwards Lifesciences, Irvine, CA) was deployed within a 28-mm model 4400 Edwards Classic Ring (Edwards Lifesciences, Irvine CA). B, C: Transesophageal echocardiography (TEE) of the newly deployed Edwards Sapien S3 valve with simultaneous color comparison showed abnormal leaflet motion (arrow) and corresponding severe mitral regurgitation secondary to leaflet malcoaptation. D, E: An X-plane image of the Edwards Sapien 3 prosthetic mitral valve depicted the native anterior mitral leaflet (arrowhead) overlaying the prosthesis and the obstruction from the anterior leaflets was the cause of the malcoaptation of one of the prosthesis leaflets (arrow). F: A third Sapien 3 valve was implanted in a telescoping fashion with significant ventricular bias in attempts to force the anterior mitral leaflet aside. G: TEE demonstrated the symmetrical coaptation and functioning of the Sapien 3 leaflets (arrow). H, I: TEE again showed normal leaflet function (arrow) with simultaneous color flow imaging (I) demonstrating resolution of the mitral regurgitation (arrow). [Color figure can be viewed at wileyonlinelibrary.com]

Fig. 3

A, B: Pre-procedural computed tomography (CT) analysis was used to simulate the 23-mm Sapien 3 valve superimposed in the mitral space and the cross-sectional area remaining in the left ventricular outflow tract (LVOT) area was estimated (bracket) at 262 mm² in the green plane depicted in panel (B). C, D: Post-Sapien 3 implantation CT LVOT measurement (bracket) demonstrated an adequate area of 271 mm² when measured at the Sapien 3 stent frame. However, since the “neo-LVOT” comprises of the stent frame and anterior mitral leaflet, it was more accurate to measure the “neo- LVOT” at the tip of the anterior mitral leaflet (arrow). This “neo-LVOT” measured 92 mm² (E and F), which could explain the flow acceleration in the LVOT after preload reduction from a dialysis session. [Color figure can be viewed at wileyonlinelibrary.com]