https://orcid.org/0000-0001-7295-1153
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Alberto Pozzoli, Mara Gavazzoni, Francesco Maisano, Maurizio Taramasso, Transcatheter mitral valve replacement after transcatheter direct annuloplasty with Cardioband, European Heart Journal, Volume 41, Issue 38, 7 October 2020, Page 3765, https://doi.org/10.1093/eurheartj/ehz337
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We present the case of a 82 years old man with severe symptomatic functional mitral regurgitation (MR) due to annular dilation and asymmetric leaflet tethering, with severe left ventricular systolic dysfunction (left ventricular ejection fraction 33%) in the setting of ischaemic cardiomyopathy (Panel A). Patient had concomitant renal dysfunction (estimated glomerular filtration rate 37 mL/min), chronic obstructive pulmonary disease, arterial hypertension, and hypercholesterolaemia. The Heart Team judged him a good candidate for Cardioband mitral direct transcatheter annuloplasty (Edwards Lifesciences, Irvine, CA, USA), which was performed under general anaesthesia, echo- and fluoro guidance. Sixteen anchors were implanted, with trivial residual MR and 1 mmHg gradient at the end of procedure (Panel B). Clinical improvement was immediately obtained and continued for 2 years, when the patient presented relapsing symptomatic MR, mainly due to further progression of cardiomyopathy causing increased leaflet tethering with good outcome of previous annuloplasty (Panel C). The attempt to correct MR with MitraClip (Abbott, CA, USA) failed, due to marked increase in gradient and left atrial pressure (mean gradient 7 mmHg with 1 NTR Clip). Eventually, patient was planned for transcatheter mitral valve replacement with Tendyne (Abbott, CA, USA). Pre-procedural planning with combination of transoesophageal echo and computed tomography (CT) was performed, calculating the systolic and diastolic dimension of neo-left ventricular outflow tract. Of note, the sizing of the Tendyne valve and landing zone on mitral annulus was preoperatively verified on the CT-derived 3D Printing model (Panels D–F). In left lateral mini-thoracotomy transapical access was obtained. A Tendyne 27 was successfully implanted in Cardioband, under echo and fluoro guidance (Panels G and H), without residual leak and 3 mmHg diastolic gradient (Panels I and L). At 1-year follow-up, the clinical and echocardiographic outcomes were excellent. This is the first case to show feasibility and safety of Valve-in-Ring implanting a Tendyne in Cardioband. Of note, direct annuloplasty, differently from other leaflet devices, keeps the door open for further treatment in case of failure of the primary treatment and recurrent MR. This element should be taken in consideration in the decisional process to select the best patient-tailored approach in each specific anatomy. These concepts are particularly important because of our moving towards combined procedures in the field of transcatheter mitral intervention.
