Long-Term Follow-Up After Dual Transcatheter Valve-in-Valve Implantation Under VA-ECMO Support

Figures

• 

  Visual Summary. Clinical Presentation, Multimodality Imaging, and Procedural Strategy in a Patient With Cardiogenic Shock Due to Simultaneous Degeneration of Aortic and Mitral Bioprostheses Stabilization with venoarterial extracorporeal membrane oxygenation enabled sequential transfemoral aortic and transseptal mitral valve-in-valve implantation, resulting in rapid hemodynamic recovery and durable valve function at 3-year follow-up. ECMO = extracorporeal membrane oxygenation; ICU = intensive care unit; TAVI = transcatheter aortic valve implantation; TMVR = transcatheter mitral valve replacement; VA-ECMO = venoarterial extracorporeal membrane oxygenation; ViV = valve-in-valve.

• 

  Figure 1. Baseline Patient Features (A) Baseline chest x-ray showing severe pulmonary congestion. (B) Severe flow acceleration noted across the aortic prosthesis. (C) The peak/mean gradient across the aortic prosthesis is 79/49 mm Hg. (D) Layered thrombus seen on interatrial septum. (E) Calcified, thick, and immobile leaflets of the mitral prosthesis. (F) Severe stenosis of the mitral prosthesis, with a peak/mean gradient of 43/30 mm Hg. (G) Three-dimensional volume rendering showing thickened and immobile leaflets.

• 

  Figure 2. Planning, Procedure, and Outcome After Valve-in-Valve TAVR (A) Multidetector computed tomography reconstruction showing dilated ascending aorta and Dacron patch. (B) Aortic prosthesis showing calcified leaflets. (C) Wide valve-to-coronary distance of 7.9 mm. (D) Aortic root angiogram showing moderate aortic incompetence. (E) Final root angiogram after TAVR shows no paravalvular leak. (F) Intraprocedural echocardiogram showing laminar flow across the aortic prosthesis. G) Low mean gradient of 6 mm Hg. TAVR = transcatheter aortic valve replacement.

• 

  Figure 3. Planning, Procedure, and Outcome After Valve-in-Valve TMVR (A) Multidetector computed tomography planning showing wide left ventricular outflow tract. (B) Septal dilatation with balloon and 2 Safari wires in the left ventricle. (C) Transcatheter mitral valve-in-valve being implanted. (D) Well-functioning mitral prosthesis. (E) No paravalvular leak. (F) Low mean gradient of 3 mm Hg. (G) Follow-up echocardiography at 3 years showing well-functioning mitral and aortic prostheses. TMVR = transcatheter mitral valve replacement.