Transcatheter Release of a Stuck Mechanical Valve in Aortic Position With Cerebral Embolic Protection

A 69-year-old man underwent aortic valve replacement (AVR) in 2000 with a 21-mm tilting disc valve. Nineteen years later, he underwent redo AVR with a 20-mm ATS AP360 valve (Medtronic) for a pannus ingrowth and an increased gradient. Three years after the second surgery, the patient presented with subacute onset of dyspnea on exertion. The international normalized ratio was 2.1. A transthoracic echocardiogram showed a mean gradient of 91 mm Hg with grade II valvular leak across the aortic mechanical valve without a thrombus. Fluoroscopic assessment revealed a decreased range of motion for both leaflets. Considering the complications of a third sternotomy because of the Society of Thoracic Surgeons risk score of 4.912, an inadequate annulus size for a bioprosthetic valve, and the last implanted mechanical valve being just 3 years old, the decision of performing transcatheter release of the stuck valve with cerebral embolic protection was made in the heart team discussion. The anterior leaflet closing angle (CA) and opening angle (OA) were 38° and 45°, respectively, and the posterior leaflet CA and OA were 25° and 55°, respectively (Figure 1A1, A2, and Supplemental Video S1). The in vitro range of movements for the ATS AP360 valve provided by the manufacturer is shown in Figure 1B. Quantitative analysis of the valve measurements was performed on the annular plane fluoroscopic image at the end of the systole (Figure 1C). Calibration was performed between the dotted blue lines using the valve size (20 mm) as the reference. Two perpendicular lines (solid white lines) were drawn from the annular plane at the hinges of the leaflets. The central orifice diameter was measured as 4 mm between the white lines. The lateral orifices were measured as 8 mm between the white and ipsilateral blue lines on each side. Cerebral embolic protection was obtained with a 6-mm spiderFX filter (Medtronic) in each internal carotid artery (Figure 1D). A 5.0-mm × 15-mm noncompliant coronary balloon dilatation over a 0.014-inch coronary wire through the central orifice of the mechanical valve (Figure 1E and Supplemental Video S2) followed by a 9.0-mm × 18-mm peripheral balloon dilatation over a 0.035-inch hydrophilic glide wire through the lateral orifice was performed (Figure 1F and Supplemental Video S3). Retrieved right-sided filter showed fibrotic embolized material (insert in Figure 1G). Histopathological examination revealed scattered lymphocytes in fibrinous proteinaceous material with foci of hemorrhage and blood clot (Figure 1G). The CAs of both leaflets became normal (25°), and the OAs were improved to 70° and 65° (Figure 1H1, H2, and Supplemental Video S4) although the normal value is 85°. The mean gradient decreased from 91 to 36 mm Hg, and the valvular leak completely disappeared at the end of the procedure and remained the same at 3 months of follow-up (Figure 1I). The first-line recommended treatment (American College of Cardiology/American Heart Association class I) for aortic mechanical valve obstruction is emergency surgery or ultraslow infusion fibrinolytic therapy using alteplase at a rate of 1 mg/h for 25 hours.1Otto C.M. Nishimura R.A. Bonow R.O. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation. 2021; 143: e35-e71PubMed Google Scholar However, in this patient, the cardiovascular surgeon turned down the third surgery because the latest redo AVR was performed just 3 years prior and the third sternotomy with the Society of Thoracic Surgeons score of 4.912 and the need for aortic root enlargement to accommodate a bioprosthetic valve would have resulted in serious complications. Moreover, because of the smaller annulus, a bioprosthetic valve would result in patient prosthesis mismatch without aortic root enlargement or, again, the mechanical valve would be the option during the third sternotomy. Fibrinolytic therapy was turned down by the patient given the possibility of stroke. Hence, transcatheter management with the cerebral embolic protection option was considered. Mechanical leaflet embolization and a stuck leaflet in the open position because of acute injury to the valve hinge are potential complications. Both of these lead to acute aortic valve insufficiency. Keeping the balloon inflated across the valve, thus converting acute valvular insufficiency into combined stenotic and regurgitant hemodynamic, and reducing the diastolic period by pacing the atrium at 120 bpm, followed by emergency surgery, were kept as bailout options. There are previously published reports of the transcatheter release of mechanical mitral valve obstruction with cerebral embolic protection.2Kalidoss L. Nandhakumar V. Subban V. Ajit M.S. Percutaneous intervention for stuck mechanical valve leaflets at mitral position.Struct Heart. 2021; 5: 427-432Abstract Full Text Full Text PDF Scopus (0) Google Scholar,3Chen Y. Waksman R. Satler L. Barnett C. Chen A. Rogers T. Percutaneous transcatheter release of stuck mechanical mitral valve leaflet.Eur Heart J. 2020; 41: 4072Crossref PubMed Scopus (1) Google Scholar There are 2 reports of balloon valvuloplasty for a stuck mechanical valve in the aortic position in the literature; however, both procedures were performed without cerebral embolic protection.4Smith D. Khurana A. Youhana A. Ionescu A. Kissing balloon “valvuloplasty” of obstructed mechanical aortic valve: when you are running out of options.JACC Case Rep. 2022; 4: 799-801Crossref PubMed Scopus (0) Google Scholar Coronary embolism and systemic embolism are potential complications. Meticulous monitoring for electrocardiogram changes and anginal symptoms during the procedure is of utmost importance to identify early coronary embolism. We used unconventional spiderFX filters, which left the vertebral arteries unprotected, because the SENTINEL system (Boston Scientific) was not available in India during the procedure. A number of new embolic protection systems are currently under clinical evaluation that can provide full coverage of the epiaortic vessels and will be ideal to use as adjuncts for transcatheter therapy for stuck mechanical leaflets.5Richter I. Abdel-Wahab M. Desch S. Thiele H. Cerebral embolic protection in patients undergoing transcatheter aortic valve implantation: Recent advances.Kardiol Pol. 2022; 80: 644-650Crossref PubMed Scopus (0) Google Scholar Peripheral embolism can be identified by performing preprocedural and postprocedural Doppler ultrasounds of upper and lower limb vessels. Bowel ischemia is another potential complication that one should keep in mind. Early mesenteric ischemia can be detected by 3- to 4-hourly monitoring of arterial blood lactate after the procedure for the next 24 hours. There was no evidence of coronary or systemic embolism in this patient. Because of a lack of robust data, transcatheter therapy should only be considered when class I recommendations are not an option in the given clinical scenario. A 69-year-old man underwent aortic valve replacement (AVR) in 2000 with a 21-mm tilting disc valve. Nineteen years later, he underwent redo AVR with a 20-mm ATS AP360 valve (Medtronic) for a pannus ingrowth and an increased gradient. Three years after the second surgery, the patient presented with subacute onset of dyspnea on exertion. The international normalized ratio was 2.1. A transthoracic echocardiogram showed a mean gradient of 91 mm Hg with grade II valvular leak across the aortic mechanical valve without a thrombus. Fluoroscopic assessment revealed a decreased range of motion for both leaflets. Considering the complications of a third sternotomy because of the Society of Thoracic Surgeons risk score of 4.912, an inadequate annulus size for a bioprosthetic valve, and the last implanted mechanical valve being just 3 years old, the decision of performing transcatheter release of the stuck valve with cerebral embolic protection was made in the heart team discussion. The anterior leaflet closing angle (CA) and opening angle (OA) were 38° and 45°, respectively, and the posterior leaflet CA and OA were 25° and 55°, respectively (Figure 1A1, A2, and Supplemental Video S1). The in vitro range of movements for the ATS AP360 valve provided by the manufacturer is shown in Figure 1B. Quantitative analysis of the valve measurements was performed on the annular plane fluoroscopic image at the end of the systole (Figure 1C). Calibration was performed between the dotted blue lines using the valve size (20 mm) as the reference. Two perpendicular lines (solid white lines) were drawn from the annular plane at the hinges of the leaflets. The central orifice diameter was measured as 4 mm between the white lines. The lateral orifices were measured as 8 mm between the white and ipsilateral blue lines on each side. Cerebral embolic protection was obtained with a 6-mm spiderFX filter (Medtronic) in each internal carotid artery (Figure 1D). A 5.0-mm × 15-mm noncompliant coronary balloon dilatation over a 0.014-inch coronary wire through the central orifice of the mechanical valve (Figure 1E and Supplemental Video S2) followed by a 9.0-mm × 18-mm peripheral balloon dilatation over a 0.035-inch hydrophilic glide wire through the lateral orifice was performed (Figure 1F and Supplemental Video S3). Retrieved right-sided filter showed fibrotic embolized material (insert in Figure 1G). Histopathological examination revealed scattered lymphocytes in fibrinous proteinaceous material with foci of hemorrhage and blood clot (Figure 1G). The CAs of both leaflets became normal (25°), and the OAs were improved to 70° and 65° (Figure 1H1, H2, and Supplemental Video S4) although the normal value is 85°. The mean gradient decreased from 91 to 36 mm Hg, and the valvular leak completely disappeared at the end of the procedure and remained the same at 3 months of follow-up (Figure 1I). The first-line recommended treatment (American College of Cardiology/American Heart Association class I) for aortic mechanical valve obstruction is emergency surgery or ultraslow infusion fibrinolytic therapy using alteplase at a rate of 1 mg/h for 25 hours.1Otto C.M. Nishimura R.A. Bonow R.O. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.Circulation. 2021; 143: e35-e71PubMed Google Scholar However, in this patient, the cardiovascular surgeon turned down the third surgery because the latest redo AVR was performed just 3 years prior and the third sternotomy with the Society of Thoracic Surgeons score of 4.912 and the need for aortic root enlargement to accommodate a bioprosthetic valve would have resulted in serious complications. Moreover, because of the smaller annulus, a bioprosthetic valve would result in patient prosthesis mismatch without aortic root enlargement or, again, the mechanical valve would be the option during the third sternotomy. Fibrinolytic therapy was turned down by the patient given the possibility of stroke. Hence, transcatheter management with the cerebral embolic protection option was considered. Mechanical leaflet embolization and a stuck leaflet in the open position because of acute injury to the valve hinge are potential complications. Both of these lead to acute aortic valve insufficiency. Keeping the balloon inflated across the valve, thus converting acute valvular insufficiency into combined stenotic and regurgitant hemodynamic, and reducing the diastolic period by pacing the atrium at 120 bpm, followed by emergency surgery, were kept as bailout options. There are previously published reports of the transcatheter release of mechanical mitral valve obstruction with cerebral embolic protection.2Kalidoss L. Nandhakumar V. Subban V. Ajit M.S. Percutaneous intervention for stuck mechanical valve leaflets at mitral position.Struct Heart. 2021; 5: 427-432Abstract Full Text Full Text PDF Scopus (0) Google Scholar,3Chen Y. Waksman R. Satler L. Barnett C. Chen A. Rogers T. Percutaneous transcatheter release of stuck mechanical mitral valve leaflet.Eur Heart J. 2020; 41: 4072Crossref PubMed Scopus (1) Google Scholar There are 2 reports of balloon valvuloplasty for a stuck mechanical valve in the aortic position in the literature; however, both procedures were performed without cerebral embolic protection.4Smith D. Khurana A. Youhana A. Ionescu A. Kissing balloon “valvuloplasty” of obstructed mechanical aortic valve: when you are running out of options.JACC Case Rep. 2022; 4: 799-801Crossref PubMed Scopus (0) Google Scholar Coronary embolism and systemic embolism are potential complications. Meticulous monitoring for electrocardiogram changes and anginal symptoms during the procedure is of utmost importance to identify early coronary embolism. We used unconventional spiderFX filters, which left the vertebral arteries unprotected, because the SENTINEL system (Boston Scientific) was not available in India during the procedure. A number of new embolic protection systems are currently under clinical evaluation that can provide full coverage of the epiaortic vessels and will be ideal to use as adjuncts for transcatheter therapy for stuck mechanical leaflets.5Richter I. Abdel-Wahab M. Desch S. Thiele H. Cerebral embolic protection in patients undergoing transcatheter aortic valve implantation: Recent advances.Kardiol Pol. 2022; 80: 644-650Crossref PubMed Scopus (0) Google Scholar Peripheral embolism can be identified by performing preprocedural and postprocedural Doppler ultrasounds of upper and lower limb vessels. Bowel ischemia is another potential complication that one should keep in mind. Early mesenteric ischemia can be detected by 3- to 4-hourly monitoring of arterial blood lactate after the procedure for the next 24 hours. There was no evidence of coronary or systemic embolism in this patient. Because of a lack of robust data, transcatheter therapy should only be considered when class I recommendations are not an option in the given clinical scenario. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.