Combined Mitral and Tricuspid Valve-in-Valve Via Transapical Approach

Using their video database between May 2015 and June 2018, the authors analyzed one case of combined THV mitral with tricuspid ViV via transapical and transjugular approach. Pre- and postoperative characteristics were analyzed in a follow-up of 20 months. 

A 36-year-old male with four previous mitral and tricuspid biological valve replacements presented at the time of the procedure with mitral and tricuspid prosthesis degeneration associated with NYHA class III, pulmonary hypertension (74 mm Hg), and right heart failure. The previous mitral valve area was of 0.8 cm², with maximum and mean gradients of 37 and 12 mm Hg and severe regurgitation. The tricuspid valve area was of 1.4 cm2, with maximum and mean gradient of 20 and 8 mm Hg. The EuroSCORE was 6.23 and STS score 0.6. 

This case was evaluated by the Heart Team and due to the high risk for a conventional operation, number of re-operations, high pulmonary hypertension and right heart failure, it was decided to treat the patient via THV ViV replacement. The operation was performed in a hybrid OR with transesophageal echocardiography and fluoroscopic guidance.

Via the transapical approach, the ventricular apex was accessed and punctured after a mini left thoracotomy. Then, via 24 fr. introducer with the aid of a stiff guidewire positioned across the mitral valve, a THV 30 mm biologic prosthesis was deployed and positioned with the aid of an expandable balloon on the MV position.

A similar procedure was performed to replace the tricuspid valve. A mini cervical right incision was performed longitudinally and the right jugular vein was individualized and punctured by direct vision. So, a 30 mm biologic THV was deployed the same way as previously described on the tricuspid valve position via trans jugular access.

The mitral and tricuspid mean gradients immediately fell, with normally functioning prosthesis. The patient was extubated in the hybrid room, remained in the ICU for three days, and was discharged from the hospital at NYHA class I. After seven months, the patient developed Infectious endocarditis that was clinically treated with third generation cefalosporin, presenting at the 20th month at NYHA class II.

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