Transcatheter Mitral Valve Therapy With Novel Supra-Annular AltaValve: First Experience in the United States

Abstract

This case demonstrates the feasibility and procedural success of a novel supra-annular transcatheter mitral valve, the AltaValve via transapical approach in a patient with severe symptomatic mitral regurgitation who was a prohibitive surgical risk candidate. (Level of Difficulty: Advanced.).

Keywords: AS, aortic stenosis; AltaValve; CT, computed tomography; LV, left ventricular; LVOT, left ventricular outflow tract; TEE, transesophageal echocardiography; TMVT, transcatheter mitral valve therapy; mitral regurgitation; supra-annular; transcatheter mitral valve therapy.

Graphical abstract

Graphical abstract

Figure 1

Pre-, Intra-, and Post-Procedural Imaging (A) Pre-procedural transthoracic echocardiography demonstrating severe mitral regurgitation. (B) Pre-procedural transesophageal echocardiography demonstrating severe mitral regurgitation. (C) AltaValve. (D) AltaValve leaflets. (E, F, G) CT images demonstrating mitral annulus. (H, I) Fluoroscopy images of valve deployment with TrueFusion guidance; the 4 markers with ring depict the mitral annular plane identified by transesophageal echocardiography. (J, K, L) Post AltaValve deployment transesophageal echocardiography images demonstrating supra-annular position, no valvular regurgitation, and mild posterior paravalvular regurgitation (red arrow). (M, N, O, P) Post-mortem images demonstrating accurate supra annular position of the AltaValve with good apposition (imprint [red arrow]) and intact leaflets (yellow arrows). (Q, R) Histopathological images demonstrating amyloidosis appearing as light-pink hyaline extracellular deposits (black arrow) displacing cardiac myocytes (yellow arrow) and apple-green birefringence under polarized light (white arrow) on Congo red–stained sections.

Figure 1

Pre-, Intra-, and Post-Procedural Imaging (A) Pre-procedural transthoracic echocardiography demonstrating severe mitral regurgitation. (B) Pre-procedural transesophageal echocardiography demonstrating severe mitral regurgitation. (C) AltaValve. (D) AltaValve leaflets. (E, F, G) CT images demonstrating mitral annulus. (H, I) Fluoroscopy images of valve deployment with TrueFusion guidance; the 4 markers with ring depict the mitral annular plane identified by transesophageal echocardiography. (J, K, L) Post AltaValve deployment transesophageal echocardiography images demonstrating supra-annular position, no valvular regurgitation, and mild posterior paravalvular regurgitation (red arrow). (M, N, O, P) Post-mortem images demonstrating accurate supra annular position of the AltaValve with good apposition (imprint [red arrow]) and intact leaflets (yellow arrows). (Q, R) Histopathological images demonstrating amyloidosis appearing as light-pink hyaline extracellular deposits (black arrow) displacing cardiac myocytes (yellow arrow) and apple-green birefringence under polarized light (white arrow) on Congo red–stained sections.