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A Case of Multivalvular Heart
Disease
Sahil Khera MD, MPH
Structural Heart and Valve Fellow
Columbia University Medical Center
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Clinical Background
• 80 year old lady with h/o HTN, HLD, Afib, NHL in
remission, RCC s/p left nephrectomy
• 27mm Edwards Magna MVR, TV ring 2012
• True Stent ID: 26mm
• High-Prohibitive STS
• Multiple readmissions for Acute Decompensated
HF
• Now NYHA IV dyspnea, LE edema, JVD
• IV diuretics
• EF 77%, serum Cr 1.09, INR 1.3, Hgb 11 , Platelets
167
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Aortic Valve
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MVR Appearance On Fluoroscopy and CT
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27mm MV Magna Valve-in-Valve App
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Mitral Valve
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Arterial Access
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Severe AS – MG 39mmHg, Vmax
4.0m/s, AVA 0.8cm2
Severe MS – MG 11mmHg, MVA
(planimetry) 1.0cm2
MVR post in LVOT, NeoLVOT
169mm2 on CT
LVH with small cavity – EF 77%
LCA height 11mm, SOV 25-
28mm, Leaflet length 12.8mm
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Concept of neo-LVOT
Blanke et al JACC Imaging 2017
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Anatomical and Device Related Factors Predisposing to Narrow the Neo-LVOT
Dimension
A parallel orientation is
associated with a lower risk of
LVOT obstruction, and a
perpendicular orientation
conferring the highest risk.
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LM protection ?
Feasibility of TMVR ?
Role of Embolic Protection?
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Plan:
TAVR with 23mm S3 with LCA
protection
TMVR with 29mm S3 with KB
in LVOT
Bailout ASA if required
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Sentinel Device
Placed via 6F RRA
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LCA Angiogram
BMW wired subsequently placed into LAD
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BAV with LCA Injection
22mm Z-NuMed balloon
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23mm S3
S3 popped up during deployment and then unable
to advance beyond MVR annular stent in aorto-
mitral curtain location
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Good LCA Flow Post TAVR
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Post BAV
Mild PVL to no PVL with BAV
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Assessment for LVOTO
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No Significant LVOT Gradient
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Post Trans-Septal
TS with Baylis sheath. Exchanged for 8.5F Agilis sheath
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Mean Trans-Mitral Gradient 12mmHg
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MV Crossing
8.5F Agilis sheath, straight wire and MPA. MPA
used to exchange for Confida wire.
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Septal Dilatation
12 x 40mm balloon
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29mm S3 with 22mm LVOT-KB
29mm S3 TMVR with deployed with 2ml extra (35ml) and
22mm NuMed LVOT balloon to tilt C3 away from LVOT
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Final Result
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Final Result
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Final Trans Mitral PG 3mmHg
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Final LVOT PG 8mmHg
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LFA Closure