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Review
. 2021 Jan;10(1):113-121.
doi: 10.21037/acs-2020-mv-104.

A step-by-step guide to transseptal valve-in-valve transcatheter mitral valve replacement

Morgan T Harloff  1 , Muntasir Chowdhury  1 , Sameer A Hirji  1 , Edward D Percy  1 , Farhang Yazdchi  1 , Hunbo Shim  1 , Alexandra A Malarczyk  1 , Piotr S Sobieszczyk  2 , Ashraf A Sabe  1 , Pinak B Shah  2 , Tsuyoshi Kaneko  1
Affiliations
Review

A step-by-step guide to transseptal valve-in-valve transcatheter mitral valve replacement

Morgan T Harloff et al. Ann Cardiothorac Surg. 2021 Jan.

Abstract

With the recent success of transcatheter aortic valve replacement (TAVR), transcatheter options for the management of mitral valve pathology have also gained considerable attention. Valve-in-valve (ViV) transcatheter mitral valve replacement (TMVR) is one such technique that has emerged as a safe and effective therapeutic option for patients with degenerated mitral valve bioprostheses at high-risk for repeat surgical mitral valve replacement. Several access strategies, including trans-apical, transseptal, trans-jugular, and trans-atrial access have been described for ViV-TMVR. Initial experiences were performed primarily via a trans-apical approach through a left mini-thoracotomy because it offers direct access and coaxial device alignment. With the advancements in TMVR technology, such as the development of smaller delivery catheters with high flexure capabilities, the transseptal approach via the femoral vein has emerged as the preferred option. This technique offers the advantages of a totally percutaneous approach, avoids the need to enter the thoracic cavity or pericardial space, and provides superior outcomes compared to a trans-apical approach. In this review, we outline key aspects of patient selection, imaging, procedural techniques, and examine contemporary clinical outcomes of transseptal ViV-TMVR.

Keywords: Valve-in-valve (ViV); transcatheter mitral valve replacement (TMVR); transseptal.

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Conflict of interest statement

Conflicts of Interest: Dr. TK, MD is a speaker for Edwards LifeSciences (Irvine, California), Abbott Laboratories (Lake Bluff, Illinois), and Medtronic (Minneapolis, Minnesota) and a consultant for Baylis (Burlington, Massachusetts) and 4C Medical (Maple Grove, Minnesota). The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Room set-up depicting both providers standing on the patient’s right side with the fluoroscopic monitors on the patient’s left.
Figure 2
Figure 2
Intra-op TEE showing the BRK Transseptal needle approaching the interatrial septum. TEE, transesophageal echocardiography.
Figure 3
Figure 3
Intra-op TEE showing the BRK Transseptal needle piercing the interatrial septum. TEE, transesophageal echocardiography.
Figure 4
Figure 4
Intra-op cath showing balloon dilation of the interatrial septum with a 14 mm balloon over the Safari wire that has been advanced through interatrial septum, across the bioprosthetic mitral valve, and into the left ventricular apex.
Figure 5
Figure 5
Intra-op cath showing positioning of the transcatheter valve within the ring of the old bioprosthetic mitral valve.
Figure 6
Figure 6
Intra-op fluoroscopy showing gradual balloon inflation and deployment of the transcatheter valve inside the bioprosthetic mitral valve.
Figure 7
Figure 7
Intra-op transesophageal echocardiogram showing successful transcatheter valve deployment.
Video
Video
A step-by-step guide to transseptal valve-in-valve transcatheter mitral valve replacement.
See this image and copyright information in PMC

References

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