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Patient Demographics: Transcatheter mitral valve implantation (TMVI) is an alternative to conventional surgery for high risk patients with severe mitral regurgitation (MR). The TendyneTM TMVI system consists of a porcine pericardial valve in a nitinol frame tethered to the left ventricular (LV) apex using an epicardial pad. The device can be used to treat primary and secondary MR, and is fully repositionable and retrievable even after complete deployment. Implantation is guided by three-dimensional transoesophageal echocardiography (3DTOE).
Relevant History: A frail 87 year-old man with previous myocardial infarction and angioectasia of stomach presented with severe mitral regurgitation due to P2 chordal rupture. He had reduced LV ejection fraction 43%), with right ventricular impairment and severe pulmonary hypertension (75mmHg). He had significant renal dysfunction (creatinine clearance 34ml/min) and raised brain naturetic peptide 470ng/L (normal 20ng/L). His logistic EuroSCORE was 20.2 and his STS PROM score was 12.6%.
Pre-Operative Plan: He was accepted for TMVI by the Heart Team.
Discussion of what was actually done and the challenges, deaths and complications encountered. (Unless case is still pending): TMVI was performed via a transapical approach using a left mini-thoracotomy. The procedure was guided by 3DTOE. Apical tether tension was adjusted to optimize device position (Figure): A: guide sheath placed across mitral valve; B-D: device progressively opened in left atrium; E-F: anterior flange of device lined up with aorta; G: device fully opened by still high in left atrium resulting in anterior paravalvular leak; H: fully deployed and correctly positioned device with no MR or paravalvular leak. TOE also established no LV outflow tract obstruction and peak mitral pressure gradient was 5mmHg. There were no VARC-2 procedural complications. The patient was discharged home on 5th post-operative day.