VIV TMVR with Sapien 3

[sevoflurane]

80 y/o s/p cabg 20 years ago. Redo sternotomy for severe Mitral regurgitaiton 15 years ago.
Other hx: Bil Fem-pop bypass, h/o stroke, severe COPD and severe pulm htn on ATC O2.
Chronic pain, CKD, etc.

Presented at valve conference for failure of mitral bpv. Mean gradient of 15 mmHg.
It was decided that we would proceed with VIV TMVR with a Sapien 3.

On paper, it sounded like a bad idea. Once I met the patient, it was clear to me she wanted this done as her severe MS was going to knock her off regardless. Nicest patient I have met in a while.

A lot of her symptoms will persist, but likely will benefit greatly from a comfort point of vew.
Hopefully some reversible cardio-pulmonary disease.

Just came here to say that pinhole MS to a 29 mm Sapien 3 without the need of a sternotomy is one of the most satisfying cases I have done in a while. Great imaging, great results... felt good.

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[nimbus]

How did you conduct the anesthetic?

 

[sevoflurane]

How did you conduct the anesthetic?

Very gently, but not that different than a sick TAVR.

Pre-induction Aline, large PIV. Minimal narcs. Maintain NSR, be prepared to treat afib, normovolemia via echo. A little longer pacing run. Careful interrogation of iatrogenic asd and development of right to left shunt as the transeptal puncture was not small.

What caught me a little off guard was the change in hemodynamics. Prior to rapid pacing, systolics were 90-100. After pacer recovery, the forward pressure was noticeable as her SBP's rapidly climbed to 170's in a matter of seconds.
MV sat beautifully over the previous BPV.
No leaks. Gradient was 3 mmHg. Some normalization of PVF.

 

[psychbender]

What caught me a little off guard was the change in hemodynamics. Prior to rapid pacing, systolics were 90-100. After pacer recovery, the forward pressure was noticeable as her SBP's rapidly climbed to 170's in a matter of seconds.

Actual forward flow from the LA to LV is an amazing thing.

 

[T-burglar]

Nice case. Did the patient tell you she felt any better? One of the things that caught me off guard when I started doing structural intervention was how much CPB / cardioplegia and sternotomy/cardiotomy depresses the circulation and obscures the immediate benefit of valve interventions.

Often the immediate hemodynamic improvement is profound.

 

[abolt18]

80 y/o s/p cabg 20 years ago. Redo sternotomy for severe Mitral regurgitaiton 15 years ago.
Other hx: Bil Fem-pop bypass, h/o stroke, severe COPD and severe pulm htn on ATC O2.
Chronic pain, CKD, etc.

Presented at valve conference for failure of mitral bpv. Mean gradient of 15 mmHg.
It was decided that we would proceed with VIV TMVR with a Sapien 3.

On paper, it sounded like a bad idea. Once I met the patient, it was clear to me she wanted this done as her severe MS was going to knock her off regardless. Nicest patient I have met in a while.

A lot of her symptoms will persist, but likely will benefit greatly from a comfort point of vew.
Hopefully some reversible cardio-pulmonary disease.

Just came here to say that pinhole MS to a 29 mm Sapien 3 without the need of a sternotomy is one of the most satisfying cases I have done in a while. Great imaging, great results... felt good.

Did the anesthetic for a couple of these in fellowship. All were super sick. Cardiologist wanted to leave the huge iatrogenic ASD open afterward on one despite her hx of stroke and bidirectional flow across it. After a little coaxing and talking about how bad it would be for her to have an uncorrected ASD of that size, he relented and closed it.

 

[DrN2O]

I did almost the exact same case a few months back. A lot things can still go wrong despite the best intentions and techniques. LVOT obstruction, pericardial effusion, etc. I still wonder if it is the best use of resources. As much as I trust my own eyeball test, sometimes Father Time knows better. Sure he looks good for his age, but nothing can compensate for the fragility of tissue in the octogenarians.

 

[pgg]

Careful interrogation of iatrogenic asd and development of right to left shunt as the transeptal puncture was not small.

Did they close the ASD or leave it alone?

I've often been surprised by how big a hole they'll just shrug off, compared to the non-iatrogenic holes they'll electively close in other patients.

An ASD with a big R to L shunt strikes me as something worth closing.

 

[sevoflurane]

Did they close the ASD or leave it alone?

I've often been surprised by how big a hole they'll just shrug off, compared to the non-iatrogenic holes they'll electively close in other patients.

An ASD with a big R to L shunt strikes me as something worth closing.

All R to L shunts are closed at the time of intervention.

This one was L to R. So we left it alone. However, they are carefully followed and scheduled for ASD closure if things get worse or don't improve. Amplatzers and other asd closure devices have their own set of risks. Recently had a big one that was 2.5-3 cm long (not iatrogenic). No rim to attach to. Had to go to the OR for surgical closure.

I did have a case that was L to R at the end of the intervention. Cards and CT went to eat. As I dialed down my anesthetic and Pulm vasc resistance increased the L to R turned into R to L with some hemodynamic instabilities. Called them back in and closed it.

Your point is well taken as these are big sheaths used to cross the septum.