Case Presentation
A 75-year-old female, with systemic hypertension, atrial fibrillation, renal failure and ischemic cardiomyopathy, presented with progressive dyspnoea (New York Heart Association functional class III) 21 months after a TMVR with the Cardioband for FMR at another institution.
During the cinching phase of the device implantation, a detachment of an anchor had been visualised at the P2 level. Periprocedural transesophageal echocardiography (TEE) revealed a residual mild MR at the end of the procedure. The patient had remained symptom-free with mild to moderate MR documented at outpatient follow-up visits until the 21st month post-implantation.
On admission, TEE showed left ventricular systolic dysfunction (ejection fraction 45%), dehiscence of the Cardioband at P2 and severe MR with two jets originating from the anterior and posterior aspect of dehiscent part of the device (Figures 1A and 1B). After multidisciplinary heart team discussion, the patient was scheduled for a minimally invasive mitral valve replacement, with a STS-PROM score of 6.08%.
A minimally invasive approach through a right anterolateral minithoracotomy was performed and the mitral valve was visualized using a three-dimensional (3D) endoscope. An endocardial ablation procedure was performed using AtriCure Cryo Module (AtriCure, Inc., West Chester, OH),. Intraoperatively, it was found that 3 anchors of the Cardioband were detached from the posterior annulus at P2 and the remaining part was highly endothelized (Figure 2A). The highly-endothelized part of the Cardioband was dissected from the surrounding annular tissue via scalpel and electrocautery (Figure 2B). Care was taken to avoid injuries of the adjacent structures such as the coronary sinus and the circumflex coronary artery; every effort was made to maintain the annular structure to avoid atrioventricular groove disruption. The time consuming part of the procedure was the removal of the Cardioband by applying a “cut and unscrew” technique. To facilitate the removal, the Cardioband was cut between the anchors and the anchors were then unscrewed by counter-clockwise rotation (Figures 2C and 2D). These manoeuvres were performed repeatedly until the last anchor was removed. Since the likelihood of successful miral repair was considered low, due to the valvular morphology, a St. Jude Medical Epic bioprosthetic mitral heart valve (St Jude Medical, Inc, St Paul, Minn) was implanted and fixed using Cor Knots (LSI SOLUTIONS, Victor, New York, USA).
The pre-discharge transthoracic echocardiography revealed a normal function of the mitral valve with a low gradient and absence of paravalvular leakage. The patient was discharged after an uneventful post-operative course.