Ventricular Embolization of Mitral Valve in Valve Rescued With a Second Valve

Keywords: mitral valve, ventricular embolization

An 89-year-old man presented with a history of redo mitral valve replacement with a 33-mm Epic valve (St Jude Medical) and tricuspid valve repair 8 years prior, atrial fibrillation, percutaneous left atrial appendage occlusion, and chronic kidney disease stage IV. He was hospitalized with acute decompensated heart failure due to bioprosthetic mitral valve failure. Transesophageal echocardiography (TEE) showed a flail prosthetic mitral leaflet and severe mitral regurgitation (MR) (Video Series). Preprocedural gated cardiac computed tomography angiography for mitral valve-in-valve (MVIV) planning showed the average internal diameter of the valve at the level of the annulus to be approximately 29 mm (Figure 1A). A 29-mm Sapien S3 virtual valve (Edwards Lifesciences) placed using 3Mensio (Pie Medical Imaging) showed clearance of 12.8 mm from the interventricular septum, a neo-LVOT area of 417 mm², and an aortomitral angle of 113° (Figure 1B). Transvenous transseptal MVIV with a 29-mm Sapien S3 Ultra valve was planned. Transseptal puncture was performed using standard techniques. The mitral prosthesis was crossed using a steerable introducer sheath and a pigtail catheter, which were then exchanged for a Safari extra-small wire (Boston Scientific). After predilating the interatrial septum with a 14-mm balloon, a 16-Fr E-sheath (Edwards Lifesciences) was inserted. The Sapien valve was mounted on the delivery catheter in the inferior vena cava and advanced across the interatrial septum without difficulty.  The central marker on the S3 was positioned a few millimeters below the sewing ring of the Epic valve and the valve was deployed under rapid ventricular pacing. Toward the end of the deployment and pacing run, the valve embolized to the ventricular side (Figures 1C and 1D; Video Series). The decision was made to attempt deploying a second valve at a proper depth to anchor the embolized valve and prevent further migration. The Safari wire was maintained in place and a second 29-mm S3 Ultra valve was advanced and positioned in the mitral annulus. The valve was successfully deployed with an excellent result with trace residual MR (Figures 1E and 1F; Video Series).

Valve embolization is a catastrophic complication of MVIV and valve-in-ring procedures, and occurs due to inadequate ventricular positioning, undersizing, or insufficient anchoring. Emergent cardiac surgery to retrieve the embolized valve is usually required for overt embolization. This case highlights the technique of deploying a second valve to anchor the embolized valve if valve migration has occurred with minimal movement.

Affiliations and Disclosures

From the Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Goel reports consultant fees from Medtronic; speaker’s bureau for Abbott Structural Heart. The remaining authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted April 13, 2022.

Address for correspondence: Sachin S. Goel, MD, Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin Street, Suite 1853, Houston, TX 77030. Email: ssgoel@houstonmethodist.org