Transcatheter Retrieval of Mitral Bioprosthetic Valve Vegetation With Extended Embolic Protection: A Case Report

Figures

• 

  Figure 1. Echocardiogram images of a mitral bioprosthetic valve (MBPV) vegetation and the gradient across the mitral valve. (A). Transesophageal echocardiogram X-plane image of the vegetation attached to the atrial side (white arrow) of the anterior cusp of the 25-mm MITRIS RESILIA valve. The vegetation measures 1.52 × 1.60 cm. (B) Continuous wave Doppler across the MBPV shows the mean gradient of 19.67 mm Hg. (C) The 3D image of the MBPV from the left atrial side shows the prolapsing vegetation in systole (black arrow). (D) The 3D image of the MBPV from the left atrial side shows the disappearance of the vegetation as it is prolapsed into the left ventricle during diastole. (E) The 3D image of the MBPV from the left ventricle side shows the well coapting cusps of the bioprosthetic valve in systole and the disappearance of the vegetation. (F) The 3D image of the MBPV from the left ventricle side shows the prolapsing vegetation (black arrow) into the left ventricle in diastole. Ao, aorta; LA, left atrium; LV, left ventricle; 3D, three-dimensional.

• 

  Figure 2. Computedtomography images of the mitral bioprosthetic valve (MBPV) vegetation. (A) A 2-chamber view at the end diastole shows a pedunculated vegetation attached to the MBPV and prolapsing into the left ventricle. (B) Cross-sectional image of a 25-mm Mitris Resilia mitral valve at the sewing ring level shows the attachment of the base of the vegetation to the anterior cusp. (C) A 2-chamber view at end systole shows a pedunculated vegetation attached to the atrial surface of the MBPV and prolapsing into the left atrium. (D) A 3D volume-rendered image shows the attachment of the vegetation to the anterior cusp of the MBPV, and it is prolapsing into the left ventricle at the end diastole. (E) A 3D volume-rendered image shows the attachment of vegetation to the atrial surface of the anterior cusp of the MBPV, which is prolapsing into the left atrium at end systole. The black arrows in the panels A-E point to the vegetation. 3D, three-dimensional.

• 

  Figure 3. Near total embolic protection using double SENTINEL filters. (A) The first SENTINEL filter is placed in the innominate artery (proximal filter [P1]) and the left common carotid artery (distal filter [D1]). The distal filter (D2) of the second SENTINEL filter is seen in the left subclavian artery. (B) The proximal filter (P2) of the second SENTINEL filter is seen in the descending thoracic aorta, which is taken through the left femoral artery. An 8.5F Agilis steerable sheath is placed across the interatrial septum from the right common femoral vein into the left atrium. A 6F Judkins left guide catheter is taken through the right femoral artery and placed in the left main coronary artery. TEE, transesophageal echocardiogram.

• 

  Figure 4. Detaching the vegetation at the pedicle. (A, B) Transesophageal echocardiogram at 120° 3-chamber view shows that a 15-mm Goose Neck snare snugly captured (yellow arrows) the mitral vegetation at the base of the pedicle in diastole and systole. (C) Fluoroscopy image of the Goose Neck snare with a 7F Judkins–right guide catheter through the Agilis sheath catching the vegetation that was attached to the atrial surface of the anterior cusp of the 25-mm MITRIS RESILIA bioprosthetic valve (yellow arrow). Ao, aorta; LA, left atrium; LV, left ventricle.

• 

  Figure 5. Snaring technique. (A) A 15-mm ensnare is advanced parallel to the vegetation in a closed position across the mitral bioprosthetic valve (MBPV) and positioned at the ventricular end of the valve. (B) The snare was opened just distal to the vegetation. (C) The snare was pulled back in an open position up to the MBPV sewing ring of MBPV. (D) The snare was tightened. LA, left atrium; LV, left ventricle; RA, right atrium.

• 

  Figure 6. Transesophageal echocardiogram mitral bioprosthetic valve (MBPV) images after the retrieval of the vegetation. (A) An X-plane view of the anterior cusp of the MBPV from 125° 3-chamber view to bicommissural view in systole shows the residual stalk of the vegetation on left atrial surface. (B) An X-plane view of the anterior cusp of the MBPV from 125° 3-chamber view to bicommissural view in diastole shows the normal opening of the leaflets. (C) The mean gradient across the mitral valve decreased from 19 to 9 mm Hg. The 3D enface view of the MBPV from left atrial side (D) and the left ventricular side (E) shows normal closure of all 3 cusps in systole. Red star marks the cusp in which the vegetation was attached. The 3D enface view of the mitral bioprosthetic valve from left atrial side (F) and the left ventricular side (G) shows restricted opening of the anterior cusp in diastole in which the vegetation was attached (red star). The other 2 cusps are normally opening. Ao, aorta; LA, left atrium; LV, left ventricle.

• 

  Figure 7. Search for the slipped vegetation from the SENTINEL filter. (A) Left subclavian artery angiogram. (B) Left brachial artery angiogram. (C) Right subclavian artery angiogram. (D) Right brachial artery angiogram shows the spasm of the brachial artery. (E) Suprarenal aortogram. (F) Infrarenal abdominal aortogram. (G) Right femoral artery angiogram. (H) Right popliteal artery angiogram shows normal trifurcation. (I) Left–popliteal artery angiogram shows embolized vegetation stuck at the trifurcation (yellow circle).

• 

  Figure 8. Gross and histopathology of the retrieved vegetation. (A) Left popliteal artery was surgically opened and the vegetation removed. (B) Gross view of the retrieved vegetation. (C) Histopathology showed aseptic thrombus with inflammatory cells comprising neutrophils and lymphocytes. (D) Thrombus showing red blood corpuscles and inflammatory cells.

• 

  Figure 9. Follow-up echocardiogram. (A) Recurrent growth of the vegetation 2 days after the retrieval (yellow arrow). (B) The mean gradient increased to 18.49 mm Hg. (C) Echocardiogram after completion of the 6-week course of antibiotics and antifungal regimens shows the disappearance of the vegetation. (D) The mean gradient across the mitral valve was 10.15 mm Hg.