Author + information
- Received December 21, 2015
- Accepted January 3, 2016
- Published online April 25, 2016.
- Pierre Deharo, MDa,
- Marina Urena, MDa,
- Dominique Himbert, MDa,∗ (, )
- Eric Brochet, MDa,
- Frederic Rouleau, MDb,
- Frederic Pinaud, MD, PhDb,
- Stephane Delepine, MDb,
- Jose Luis Carrasco, MDa,
- Walid Ghodbane, MDa,
- Fabrice Extramiana, MDa,
- Phalla Ou, MD, PhDa,
- Marie Pierre Dilly, MDa,
- David Messika-Zeitoun, MD, PhDa,
- Bernard Iung, MD, PhDa,
- Patrick Nataf, MDa and
- Alec Vahanian, MDa
- aBichat Claude Bernard Hospital-Paris VII University, Paris, France
- bAngers University Hospital, Angers, France
- ↵∗Reprint requests and correspondence:
Dr. Dominique Himbert, Bichat Claude Bernard Hospital-Paris VII University, 46 Henri Huchard, 75018 Paris, France.
- alcohol septal ablation
- left ventricular outflow obstruction
- mitral annular calcification
- transcatheter mitral valve implantation
A 76-year-old woman with degenerative mitral valve disease was referred for refractory heart failure. An echocardiogram showed the presence of a massive mitral annular calcification with severe stenosis (mitral valve area, 1.0 cm2; mean gradient, 11 mm Hg) and a small left ventricular cavity with a 23-mm septal bulge without obstruction (Figures 1A to 1C, Online Video 1). Computed tomography (CT) findings were almost circumferential calcification of the mitral annulus; mitral annulus diameter of 22.8 × 30.0 mm and area of 472 mm2, and mitral annulus-aorta angle of 122° (Figures 1D to 1F).
The heart team recommended a transcatheter mitral valve replacement (TMVR). The procedure was performed via the transseptal approach using a 26-mm SAPIEN 3 valve (Edwards Lifesciences, Irvine, California) (Online Video 2). Immediately after deployment, the patient had severe hypotension requiring hemodynamic support (Figures 2A and 2B). An echocardiographic assessment showed a satisfactory function of the prosthesis (trace paravalvular leak and a mean gradient of 5 mm Hg), which contacted the septum, leading to a severe left ventricular outflow tract (LVOT) obstruction with a maximal gradient of 100 mm Hg (Online Video 3), confirmed by hemodynamic measurements (Figure 2B). Bail-out septal alcohol ablation was performed (Figures 3A to 3C) with an initial restoration of systemic pressure and a marked decrease in LVOT gradient (Figures 3D and 3E). A few hours later, a permanent pacemaker was implanted because of a secondary increase in the LVOT gradient. Thereafter, the evolution was favorable, and the patient was discharged on day 12. Six months after the procedure, the patient was in New York Heart Association functional class II. Echocardiographic and CT images confirmed an adequate prosthesis placement and function (Online Video 4) and a maximal LVOT gradient of 25 mm Hg.
Severe LVOT obstruction is life-threatening complication of TMVR. A septal bulge with a small left ventricular cavity increases the risk of this complication. Therefore, left ventricular morphology should be carefully evaluated before the procedure, and contraindication to the intervention should be considered if such features are observed. If severe LVOT obstruction occurs, bail-out alcohol septal ablation may be lifesaving.
For supplemental videos, please see the online version of this article.
Dr. Himbert is a consultant for Edwards Lifesciences and a proctor for Medtronic. Dr. Iung is a consultant for Abbott Vascular Boehringer Ingelheim and has received speakers fees from Edwards Lifesciences. Dr. Nataf is a former proctor for Edwards Lifesciences. Dr. Vahanian has received speakers fees from Abbott Vascular, Edwards Lifesciences, and Valtech; and is on the Advisory Board of Medtronic. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Deharo and Urena contributed equally to this work.
- Received December 21, 2015.
- Accepted January 3, 2016.
- American College of Cardiology Foundation