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Venoarterial Extracorporeal Membrane Oxygenation to Facilitate Transcutaneous Mitral Valve Replacement in Critical Mitral Stenosis

ABSTRACT: Biological mitral valve restenosis after replacement in rheumatic heart disease is a rare complication. This case illustrates venoarterial extracorporeal membrane oxygenation to facilitate transcatheter mitral valve replacement in a patient with suprasystemic pulmonary pressure and cardiogenic shock with multiorgan failure secondary to critical mitral stenosis of a bioprosthetic valve.(Level of Difficulty: Advanced.) Central Illustration

SUBMITTER: Clark R

PROVIDER: S-EPMC9175201 | biostudies-literature | 2022 Apr

REPOSITORIES: biostudies-literature

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Project description:BackgroundBioprosthetic mitral valves on average have a median durability between 8 and 10 years. After the failure of a bioprosthetic valve, surgical replacement is often indicated. However, the options for those patients at high or prohibitive surgical risks are limited. Here, we describe a case of a successful trans-catheter mitral valve-in-valve (TMViV) replacement on venoarterial extracorporeal membrane oxygenation (VA-ECMO).Case summaryWe describe a case of a 39-year-old female with a history notable for systemic lupus erythematosus, severe pulmonary arterial hypertension (now mixed pre and post) thought to be secondary to prior substance use, and infective endocarditis complicated by severe mitral stenosis status post-bioprosthetic mitral valve replacement who presented with symptoms of acute hypoxic respiratory failure secondary to severe bioprosthetic mitral valve stenosis. The patient had a prolonged hospital course complicated by a pulseless electrical activity arrest, (continuous renal replacement therapy) for acute renal failure, and hypertonic saline due to cerebral oedema. Due to her significant co-morbidities and haemodynamic instability with acute kidney injury and recent neurologic insult, the patient was thought not to be a good surgical candidate. However, given her young age and overall improved neurologic status, it was thought the patient could benefit from a TMViV with bi-ventricular support given her right- and left-sided heart failure and was placed on VA-ECMO in anticipation of a TMViV procedure for circulatory support. The patient underwent a successful TMViV replacement using a trans-septal approach with a 26 mm SAPIEN 3 valve and atrial septal defect closure with a 14 mm Amplatzer device on hospital Day 12. The patient was successfully de-cannulated from VA-ECMO on hospital Day 13. The patient had a prolonged hospital course but eventually had renal recovery and tracheostomy de-cannulation. A trans-thoracic echocardiogram prior to discharge was notable for a well-functioning valve and normal ejection fraction. The patient was discharged to a nursing home for further rehabilitation.DiscussionThe gold standard for bioprosthetic mitral valve stenosis is surgical replacement of the valve. However, the options for those at high or prohibitive surgical risk are lacking. Recent studies have demonstrated TMViV is a safe alternative to surgical mitral valve redo cases in high-risk patients. To our knowledge, there are limited data on trans-catheter valve placement while on VA-ECMO. Successful implantation in our patient suggests that TMViV in a stenotic bioprosthesis is feasible in very high-risk patients with the use of VA-ECMO to support haemodynamics.

Project description:BackgroundThere are limited data on the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or cardiopulmonary bypass (CPB) to provide hemodynamic support periprocedurally during transcatheter aortic valve replacement. This study sought to evaluate patients receiving transcatheter aortic valve replacement with concomitant use of CPB/VA-ECMO.Methods and resultsWe systematically reviewed the published literature from 2000 to 2018 for studies evaluating adult patients requiring CPB/VA-ECMO periprocedurally during transcatheter aortic valve replacement. Studies reporting short-term and long-term mortality were included. Given the significant methodological and statistical differences between published studies, meta-analysis of the association of CPB/VA-ECMO with mortality was not performed. Of the 537 studies identified, 9 studies representing 5191 patients met our inclusion criteria. Median ages were between 75 and 87 years with 33% to 75% male patients. Where reported, the Edwards SAPIEN™ transcatheter heart valve was the most frequently used. A total of 203 (3.9%) patients received periprocedural hemodynamic support with CPB/VA-ECMO. Common indications for CPB/VA-ECMO included left ventricular or aortic annular rupture, rapid hemodynamic deterioration, aortic regurgitation, cardiac arrest, and left main coronary artery obstruction. The use of CPB/VA-ECMO was predominantly an emergent strategy and was used for durations of 1 to 2 hours. Short-term mortality (in-hospital and 30-day) was 29.8%, and 1-year mortality was 52.4%. Major complications such as bleeding, vascular injury, tamponade, stroke, and renal failure were noted in 10% to 50% of patients.ConclusionsCPB/VA-ECMO was used in 4% in the early experience of patients undergoing transcatheter aortic valve replacement, most commonly for periprocedural complications. There are limited data on preprocedural planned use of VA-ECMO, and the characteristics of this population remain poorly defined.

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Venoarterial Extracorporeal Membrane Oxygenation to Facilitate Transcutaneous Mitral Valve Replacement in Critical Mitral Stenosis

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