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A Case of Multivalvular Heart
Disease
Sahil Khera MD, MPH
Structural Heart and Valve Fellow
Columbia University Medical Center
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
Aortic Valve
MVR Appearance On Fluoroscopy and CT
27mm MV Magna Valve-in-Valve App
Mitral Valve
Arterial Access
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
Concept of neo-LVOT
Blanke et al JACC Imaging 2017
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.
LM protection ?
Feasibility of TMVR ?
Role of Embolic Protection?
Plan:
TAVR with 23mm S3 with LCA
protection
TMVR with 29mm S3 with KB
in LVOT
Bailout ASA if required
Sentinel Device
Placed via 6F RRA
LCA Angiogram
BMW wired subsequently placed into LAD
BAV with LCA Injection
22mm Z-NuMed balloon
23mm S3
S3 popped up during deployment and then unable
to advance beyond MVR annular stent in aorto-
mitral curtain location
Good LCA Flow Post TAVR
Post BAV
Mild PVL to no PVL with BAV
Assessment for LVOTO
No Significant LVOT Gradient
Post Trans-Septal
TS with Baylis sheath. Exchanged for 8.5F Agilis sheath
Mean Trans-Mitral Gradient 12mmHg
MV Crossing
8.5F Agilis sheath, straight wire and MPA. MPA
used to exchange for Confida wire.
Septal Dilatation
12 x 40mm balloon
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
Final Result
Final Result
Final Trans Mitral PG 3mmHg
Final LVOT PG 8mmHg
LFA Closure
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