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.