Successful Treatment of Early Bioprosthetic Mitral Valve Fusion in a Patient on VA ECMO With Balloon Valvuloplasty Via Direct Cannulation of Pulmonary Vein

We present a case of a 57-year-old male who underwent bioprosthetic mitral valve replacement (MVR) and developed postoperative cardiogenic shock requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) and Impella 5.5 (Abiomed) hemodynamic support. After 14 days on VA ECMO and Impella 5.5, echocardiography revealed complete fusion of the bioprosthetic mitral valve leaflets, resulting in severe mitral stenosis (mean gradient of 14 mm Hg) and 0.3 cm2 valve area. The patient was deemed high risk for repeat surgery due to comorbidities, and thus, a minimally invasive approach was pursued.  Mitral valvuloplasty was deemed the appropriate intervention.

Via direct cannulation of the right superior pulmonary vein an 8-French 23-cm AVANTI+ sheath introducer (Cordis) was advanced into the left atrium (Figures 1, 2). A Confida wire (Medtronic) was then advanced into the left ventricle. A 22 x 5-mm Tyshak II balloon (B. Braun) was placed across the mitral valve (Figure 3) and adequately inflated resulting in immediate improvement in valve function (mean gradient of 3 mm Hg) and valve area 1.5 cm2 (Figure 4). The pulmonary vein was closed with a 4-0 Prolene polypropylene suture (Ethicon). Intraoperative echocardiography demonstrated significant leaflet motion improvement. Subsequently, the patient’s hemodynamics improved and ECMO was removed. The Impella was removed 9 days later.

Our technique involves the placement of a balloon catheter through the right superior pulmonary vein and inflation in the stenotic valve to break up adhesions to improve valve function. This approach is particularly attractive in high-risk patients who are deemed unsuitable for repeat open heart surgery due to comorbidities or advanced age. Our report is the first known case of direct pulmonary vein cannulation for mitral valvuploplasty.

Affiliations and Disclosures

From the Maimonides Medical Center, Brooklyn, NY, USA.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence:  Richard Casazza, MA S, RT(R)(CI), Maimonides Medical Center, 4802 10th Avenue, Brooklyn NY 11219, USA. Email: all4ugq@aol.com