Transcatheter Mitral Valve Replacement in High-Surgical Risk Patients: A Single-Center Experience and Outcome.

Background: Re-operative mitral valve (MV) replacement is a high-risk procedure, therefore, transcatheter MV replacement (TMVR) is a promising therapeutic option. Aim: In this study, we aimed to evaluate the feasibility and safety of TMVR in patients with high surgical risk with degenerated mitral bioprostheses (TMViV), failed surgical rings (TMViR), and mitral annular calcification (TMViMAC). Methods: This is a retrospective cohort study that enrolled patients with high surgical risk who underwent TMVR from February 2017 to September 2020. The TMVR procedure was performed using Edwards SAPIEN-3 valves through the transseptal approach. Results: Sixty-four patients aged 62.7 ± 16.1 years with an STS score of 9.2 ± 3.7% underwent TMVR [35 (55%) TMViV, 16 (25%) TMViR, and 13 (20%) TMViMAC]. Mitral stenosis was more frequent in TMViV, mitral regurgitation was more frequent in TMViR, and combined mitral stenosis and regurgitation were more frequent in TMViMAC (P < 0.05). The MV gradient was 14.3 ± 5.3 mmHg and the MV area was 1.5±0.6 cm2. The 29 mm valve was frequently used in TMViV and TMViMAC, while the 23 mm valve was frequently used in TMViR (P=0.003 ∗ ). The procedural and fluoroscopy times were 58.7 ± 8.9 and 41.1 ± 8.2 minutes, respectively. Technical success was reported in 62 (98.4%) patients; 1 TMViR patient experienced valve embolization and salvage surgery, and 1 TMViMAC patient experienced slight valve malposition. At 3 months, 2 (3.1%) patients showed valve thrombosis (treated with anticoagulation), and 1 (1.6%) patient developed a paravalvular leak (underwent surgical MV replacement). At 6 months, 3 (4.7%) patients showed valve degeneration (underwent surgical MV replacement). Throughout follow-up, no patient exhibited mortality. Conclusions: TMVR is a feasible and safe approach in patients with high surgical risk. TMViV and TMViR are reasonable as the first treatment approaches, and TMViMAC seems encouraging.

A Comparative Study of TAVR versus SAVR in Moderate and High-Risk Surgical Patients: Hospital Outcome and Midterm Results.

BACKGROUND: Although the use of transcatheter aortic valve replacement (TAVR) has recently become an attractive strategy in prohibitive surgical high-risk patients undergoing aortic valve replacement (AVR), the most appropriate treatment option in patients with an intermediate- to high-risk profile- whether conventional surgery (SAVR) or TAVR-has been widely debated. METHODS: One hundred and forty-three consecutive patients with intermediate to high risk were prospectively enrolled and selected to undergo SAVR (Group 1 [G1], n = 63) or TAVR (Group 2 [G2], n = 80) following a multidisciplinary evaluation including frailty, anatomy, and degree of atherosclerotic disease of the aorta/peripheral vessels. The mean logistic EuroSCORE (G1 = 20.11 ± 7.144 versus G2 = 23.33 ± 8.97; P = .022), STS score (G1 = 5.722 ± 1.309 versus G2 = 5.958 ± 1.689; P = .347), and preoperative demographics such as sex, left ventricular ejection fraction (LVEF),  body mass index (BMI), peripheral vascular disease, diabetes, atrial fibrillation, renal impairment and syncope were similar. Of note, chronic obstructive pulmonary disease was more frequent in TAVR patients (G2 [46.2%] versus G1 [19.0%]; P = .001), whereas pulmonary hypertension was more frequent in SAVR group (G1 [47.6%] versus G2 [17.5%]; P = .000). The SAVR was performed with either a mechanical or tissue valve; meanwhile, TAVR was performed with either Core valve prosthesis or Edwards-Sapiens XT valve. RESULTS: SAVR group showed higher incidence of some postoperative complications compared to TAVR, namely, postoperative bleeding (4.8% versus 0.0%; P = .048), tamponade (4.8% versus 0.0%; P = .048) and postoperative atrial fibrillation (34.9% versus 10.0%; P = .000), whereas TAVR group had a higher incidence of other sets of postoperative complications, namely, left bundle branch block (58.8% versus 4.8%; P = .000), need for permanent pacemaker implantation (25.0% versus 1.6%; P = .000) and peripheral vascular complications (15.0% versus 0.0%; P = .001). On the contrary, when the two groups were compared they did not show any significant difference regarding anemia requiring more than two units of blood transfusion, postoperative renal failure, stroke, myocardial infarction, and hospital mortality. P = .534, .873, .258, .373 and .072 respectively. Hospital mortality was similar among the two groups (G1 = 0% versus G2 = 5%; P = .072). At the 24-month follow-up, overall mortality, major adverse cardiac and cerebrovascular events were comparable between the two groups but prosthetic regurgitation was better in SAVR group (G2 = 8 patients [10.0%] versus G1 = 1 patient [1.6%] in SAVR group; P = .040). CONCLUSION: In this study, we could not detect an advantage in survival when SAVR or TAVR were utilized in intermediate to high surgical risk patients needing aortic valve replacement for severe aortic stenosis.

Transcatheter Mitral Valve Repair Technique in Specific Severe Mitral Regurgitation: Tips, Tricks, and Outcomes.

Background: In specific patients with severe mitral regurgitation (MR), mitral valve (MV) pathology is unique and requires creative transcatheter repair techniques. This study aimed to evaluate the feasibility and safety of a new transcatheter MV repair technique, using occluder devices in symptomatic high-surgical-risk patients with severe MR, either due to MV leaflet (MVL) perforations or due to post-clips residual MR, and to report on their 6-month outcomes. Methods: The study enrolled all high-risk patients with severe MR due to MVL perforations and post-clips residual MR who underwent transcatheter MV repair using occluder devices, from November 2016 to August 2019. Results: The study enrolled 16 patients; 9 (56.25%) with MVL perforations and 7 (43.75%) with post-MitraClip (Abbott Laboratories, Abbott Park, Illinois) residual MR, with a mean age of 55.75 ± 16.69 years. Mean perforation/jet diameters were 5.75 ± 1.67 and 6.5 ± 1.93 mm, and the mean 3D-vena contracta area was 0.54 ± 0.14 cm2. Perforations were crossed retrograde (transaortic in 7 [43.75%] patients and transapical in 2 [12.5%] patients), and post-MitraClip devices residual jets were crossed antegrade (transvenous/transseptal). Six (37.5%) patients required arteriovenous loop formation for device deployment, that was antegrade transvenous/transseptal in 13 (81.25%) patients and retrograde transapical in 3 (18.75%) patients. Devices used were Amplatzer-ASO in 10 (62.5%) patients and Amplatzer-VP-II in 6 (37.5%) patients. Mean procedural and fluoroscopy times were 55.13 ± 16.24 and 16.25 ± 4.03 â€‹minutes, respectively. Patients passed successfully, without MV gradient change or device-related complications. Conclusions: Transcatheter MV repair of MVL perforations/post-clips residual MR is a new, feasible, and safe technique for high-surgical-risk patients.

Transcutaneous closure of a huge multilocular coronary to right atrium fistula causing severe right side heart failure: A case report.

Coronary artery fistula (CAF) is a congenital connection between a coronary artery and cardiac chambers, or a vessel bypassing a capillary system. The clinical presentation of congenital CAF varies, depending on its size and the draining chamber. A 40-year-old female presented with right-sided heart failure and was diagnosed by transthoracic echocardiography and computed tomography with 3D printing to have substantial coronary to right atrium fistula. Left main artery was cannulated to the outlet of the fistula at the base of the superior vena cava to the right atrium. The wire snared and created the arterio-venous loop. A 7F delivery sheath through the arterio-venous loop landed in proximal left circumflex part of the fistula, Amplatzer duct occluder I size 12/10 selected with the distal (aortic) skirt positioned distal to the most distal visible coronary branch. We waited for 10 min monitoring the ST segments for any changes. Finally, the device was released with complete closure of the fistula sparing all coronary branches. Follow-up transthoracic echocardiography after six months showed no flow to fistula sacs; the patient's symptoms improved dramatically. In conclusion, transcatheter closure of an isolated enormous multiloculated CAF is feasible and relatively safe. Surgery should be reserved for CAF with failed percutaneous closure. .

Management of severe haemolytic anaemia due to residual small mitral paravalvular leak post-percutaneous closure: a case report.

BACKGROUND: Haemolytic anaemia is a complication of paravalvular leak (PVL). The correlation between the size of the leak and the severity of haemolysis is unclear. Small leaks can cause severe haemolysis, whereas significant leaks may cause no haemolysis. CASE SUMMARY: We report the case of a 40-year-old male who underwent mechanical mitral and aortic valve replacement 20 years ago. In the last 3 years, the procedure was repeated three times due to infective endocarditis. He presented with severe shortness of breath. A transoesophageal echocardiogram with three-dimensional surgical view showed that both discs of the mechanical mitral valve opened sufficiently but a severe PVL had occurred at the 9-12 o'clock position. The location of the mitral valve was abnormal, the sewing ring was inserted high at the mid-interatrial septum. The mechanical aortic valve functioned well. Closure of the transcutaneous PVL was accomplished with two percutaneously implanted devices, leaving a small leak in between. After closure, he developed haemolytic anaemia (haemoglobin: 6 g/dL, lactate dehydrogenase: 1896 units/L, reticulocyte count: 4.6%). He then received 16 units of packed red blood cells. He developed acute kidney injury and was started on haemodialysis. We then installed two additional devices to completely close the mild residual leak and another device to resolve the bidirectional transseptal defect. After 2 days, his renal function returned to normal and anaemia improved (haemoglobin: 9.1 g/dL). DISCUSSION: Mild residual paravalvular leak can cause severe haemolytic anaemia that is correctable via percutaneous closure of the leak.

Assessment of Left Ventricular Mechanics in Patients with Severe Aortic Stenosis after Transcatheter Aortic Valve Implantation: 2-D Speckle Tracking Imaging Study.

BACKGROUND: Chronic pressure overload secondary to severe aortic stenosis causes impairment of left ventricular myocardial deformation and associated with adverse outcome. The present study aimed to assess the response of myocardial mechanics after transcatheter aortic valve implantation (TAVI). METHODS: Assessment of myocardial mechanics by quantification of LV longitudinal, circumferential strain and rotational deformation (apical, basal rotation and twist) by 2-D Speckle-tracking echocardiography at baseline and at midterm follow-up post-TAVI. The patients were divided into 2 groups based on baseline left ventricular ejection fraction. 46 patients had preserved LV EF ≥50% preserved ejection fraction (PEF) and 34 patients had reduced left ventricular ejection (REF) < 50%. RESULTS: 80 patients with severe AS and high surgical risk were evaluated. At a mean follow-up of 8 ± 3 months after TAVI, left ventricular longitudinal strain (LS) significantly improved in reduced ejection fraction (REF) group from -9.88 ± 3.93% to 11.89 ± 3.15% (P = 0.001). In preserved ejection fraction (PEF) group, longitudinal strain improved from -13.8 ± 3.1% to -15.2 ± 3.3% (P < 0.001). Longitudinal strain rate (LSR) improved significantly in REFgroup, -0.48 ± 0.20sec-1 to -0.62 ± 0.16 sec-1 (P < 0.001) and in PEF group,-0.73 ± 0.19 sec-1 to-0.77 ± 0.16 sec -1 (P < 0.005). In PEF group, LV twist angle was supra-physiological at baseline and decreased after TAVI towards normal values (P = 0.006). In REF group LV twist angle was reduced at baseline with significant increase towards normal value after transcatheter aortic valve implantation (TAVI),P = 0.005. That was attributed to severe LV dysfunction associated with reduction of left ventricular twist at baseline which improved in response to TAVI alongside with improvement of left ventricular systolic function. In reduced ejection fraction (REF) group circumferential strain and strain rate improved significantly after TAVI. CONCLUSIONS: Myocardial mechanics of the left ventricle including strain, strain rate and twist are deformed in severe aortic stenosis. TAVI restores myocardial mechanics towards physiological values in patients with preserved and reduced ejection fraction.

Concomitant transcatheter closure of post-myocardial infarction ventricular septal defect and inferior wall aneurysm: case report.

BACKGROUND: The incidence of the post-infarct ventricular septal defect (VSD) is 0.17%. Surgical repair is the definitive treatment and percutaneous closure is an alternative in high-risk patients. We report a case of post-myocardial infarction inferior wall aneurysm associated with a large ventricular septal rupture, with a communication between the aneurysm and right ventricle. Successful percutaneous closure of both the aneurysm and the post-infarct (VSD) was performed using two Amplatzer septal occluder devices. CASE SUMMARY: A 76-year-old man was referred to the clinic 2 weeks after an inferior wall myocardial infarction. A harsh, pansystolic murmur was appreciated on his left parasternal area and across the pericardium. An echocardiogram demonstrated a large, true aneurysm in the mid-cavity inferior wall. The inferior septum was ruptured and dissected, with a large, left-to-right shunt. The patient's coronary angiography revealed a multi-vessel disease. The patient was considered as high surgical risk and thus transcatheter closure of both the post-infarct VSD and inferior wall aneurysm was recommended. We crossed the VSD from the venous side. An Amplatzer septal occluder (18 mm) was deployed to close the VSD completely. We crossed the aneurysm mouth from the arterial side. Another Amplatzer septal occluder (26 mm) was deployed with the large disc inside the aneurysm, sealing it with no more flow. After discharge from the intensive care unit, the patient underwent complete revascularization for his right coronary artery, left main artery, proximal left anterior descending artery, and ramus intermedius. At his 3-month follow-up, the patient remained well with reasonable exercise tolerance. DISCUSSION: Percutaneous closure of a post-infarct VSD and aneurysm is an option for patients whose comorbidities preclude surgical repair and whose septal anatomy is favourable to device placement.

Percutaneous closure of iatrogenic anterior mitral leaflet perforation: a case report.

BACKGROUND: Severe mitral regurgitation (MR) through the body of the anterior mitral leaflet (AML) is rare. The cause either iatrogenic during open-heart surgery or due to infective endocarditis. We present a case where a successful percutaneous closure of the AML perforation was an alternative to surgery. CASE SUMMARY: A 60-year-old male presented with shortness of breath (SOB) class III of 12 months duration. He underwent coronary artery bypass surgery with four grafts plus mitral valve (MV) repair 20 months ago. Transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE) revealed severe MR through the body of AML at A3. The percutaneous closure plan was to cross the AML perforation from the left ventricular side. The venacontracta of the perforation was 6 mm, an amplatzer septal occluder device 6 mm considered appropriate for closure of this hole. A snare catheter snared the wire and exteriorized creating arteriovenous loop. Amplatzer septal occluder 6 mm loaded to the delivery system till larger disc (left-sided) opened safely and freely below the MV apparatus. Once the left ventricular side disc opposed the ventricular surface of AML, the waist and left atrial disc gently released. The patient discharged in the next day. After 6 months, the patient had no more SOB, he returned to his daily activity. Follow-up TTE showed no MR, the closure device was stable in place. DISCUSSION: We added a successful case of transcatheter AML perforation to the literature. The role of TOE is crucial in diagnosis and procedure guidance.

Percutaneous Tricuspid Valve in Failed Annuloplasty Ring and Paravalvular Leak Closure for Mechanical Aortic Valve.

Transcatheter valvular interventions are established as an alternative for surgery in selected patients in symptomatic high surgical risk patients. Tricuspid valve replacement after failed repair ring had limited experience to date. We report this case to highlight the procedure details and results.

Diathermy-assisted recanalization of chronic superior vena cava obstruction, case report.

The number of cases of superior vena cava syndrome (SVCS) increased due to increased cardiac devices and central venous catheters. Management of benign SVCS is still controversial. A 51-year-old male known to have ischemic cardiomyopathy and chronic renal failure on regular hemodialysis. In the last 12 months, he had progressive shortness of breath and swelling of his upper part of the body. Examination revealed engorgement of the neck veins, facial puffiness, and pitting edema of both upper limbs. Venography showed occluded SVC. We applied a 50 Watt of energy via electrocautery pen to a Hi-Torque 0.014 Astato guidewire to cross the occluded segment retrogradely. We used 2 stents 39 mm, mounted on BIB 20/40 mm. Final angiography revealed full restoration of SVC flow. Diathermy use to cross a chronic total SVC obstruction is feasible and safe. Endovascular techniques are suitable as initial management of benign SVC syndrome.

Transesophageal echocardiography guidance of percutaneous mitral valve replacement in failed annuloplasty ring: A case report.

Severe mitral regurgitation and stenosis due to failed mitral annuloplasty ring can be managed with percutaneous mitral valve in ring in high surgical risk patients. A 66-year-old male underwent coronary artery bypass surgery and mitral valve ring annuloplasty 7 years previously. He started to have shortness of breath with minimal effort in the past 2 years. Transthoracic echocardiogram revealed a new severe mitral regurgitation and severe mitral stenosis. The patient was turned down from surgery due to high surgical risk. The transcatheter mitral valve in ring implantation was decided. In this case, there was a low probability of left ventricular outflow tract obstruction. A stiff wire crossed the mitral valve ring and positioned in the left ventricular apex. The Sapien 3 valve size 26 mm (Edwards Lifesciences, Irvine, CA, USA) was positioned to have 80% ventricular and 20% atrial side. Transesophageal echocardiogram evaluation revealed a mean gradient of 5 mmHg. The left ventricular outflow tract (LVOT) had laminar color flow and the mean pressure gradient across LVOT was 1 mmHg. The patient was discharged after 2 days in good condition. At one year follow up, he had no shortness of breath and no rehospitalization. In conclusion, the percutaneous mitral valve in ring is feasible in selected patients. The risk of LVOT obstruction should be assessed carefully before the procedure with a transthoracic and transesophageal echocardiogram. 〈Learning objective: Understand how to guide the mitral valve in ring procedure with a transesophageal echocardiogram and how to avoid left ventricular outflow tract obstruction. Understand how to position the Sapien valve in mitral valve ring.〉.

Percutaneous closure of ruptured noncoronary sinus of Valsalva to right atrium causing severe right heart failure, a case report.

In all young and middle-aged patients presenting with symptoms of acute heart failure and new heart murmurs, sinus of Valsalva aneurysm (SVA) rupture should be considered in the differential diagnosis. Most of SVAs rupture into the right side of the heart. Percutaneous closure is a less invasive alternative to surgery. A 25-year-old man presented with shortness of breath New York Heart Association class III of nine months' duration with a progressive course. He had a continuous murmur with maximum intensity over the left sternal border and propagated all over the pericardium. Chest radiographs revealed moderate congestion. Transthoracic and transesophageal echocardiograms with 3D imaging revealed a shunt between the ruptured noncoronary SVA and the right atrium. Percutaneous closure decided; the wire passed from superior vena caca through the ruptured sinus to the aorta. The distal disc of the device deployed in the aorta and the proximal disc in the right atrium. The ruptured aneurysm closed with no more flow to the right atrium. The patient was discharged from the hospital after two days. In conclusion, device closure of ruptured coronary sinus to the right atrium is feasible and safe. Surgery should be reserved for patients with failed device closure. .

Cardiovascular magnetic resonance and echocardiographic findings of a large thrombosed intramyocardial dissecting hematoma: a case report and a brief review of literature.

Intramyocardial dissecting hematoma (IMDH) is an uncommon fatal complication after acute myocardial infarction. It is usually under identified. Transthoracic echocardiography is the first-line modality that can detect IMDH. Cardiac magnetic resonance could confirm the diagnosis. In this paper, we reported a unique partially thrombosed large left ventricle IMDH that mimics thrombosed true aneurysm aiming to highlight the supporting diagnostic transthoracic echocardiography and cardiac magnetic resonance criteria of IMDH.

Treatment of severe mitral regurgitation that mimics a para-ring mitral regurgitation after failed annuloplasty ring with MitraClip: A case report.

BACKGROUND: Progressive remodelling of the left ventricle with lateral and apical displacement of one or both papillary muscles can lead to recurrence of severe mitral regurgitation (MR) in the presence of the mitral valve (MV) ring. The MitraClip (Abbott, USA) is the only option in cases with annuloplasty rings too large for implantation of a Sapien prosthesis in high surgical-risk patients. We present a case where the MR jet was directed toward a para-ring hole, and the MitraClip system was used successfully to treat this severe MR. CASE SUMMARY: An 80-year-old woman underwent coronary artery bypass surgery plus MV repair with C-shaped ring 6 years ago. In the past year, she experienced severe shortness of breath; her ejection fraction dropped to 15%. A transesophageal echocardiogram revealed that severe MR started at the level of MV leaflets and then passed to the left atrium beside the MV ring. Live 3D showed the severe MR coming through the oval-shaped hole beside the C-shaped MV repair ring. MitraClip implantation was decided, the two leaflets were grasped successfully, the clip was fully closed, and only trace MR remained at the MV leaflets with no flow to the para-ring hole. The patient was extubated after 12 hours and discharged home after 2 days. Follow-up transthoracic echocardiography after 6 months showed the clip in place and trace residual MR. CONCLUSION: Implantation of MitraClip in the presence of MV repair ring is feasible and safe. The para-ring defect can be left if the origin of MR from the MV coaptation line is treated successfully with MitraClip. Symptomatic improvement with no rehospitalization was documented in this case.

Ultraslow thrombolytic therapy in stuck mechanical aortic valve, case report, and review of the literature.

BACKGROUND: Stuck mechanical heart valves had a debate about the management plan. There is debate regarding the type, dose, and rate of administration of various thrombolytic agents. We report a case with successful thrombolysis using an ultraslow regimen. CASE SUMMARY: A 43-year-old female with a history of aortic valve (AV) and mitral valve replacement (bi-leaflet metallic valves), and tricuspid valve repair (MINI band) at October 2017. Physical examination showed normal metallic first heart sound and weak metallic second heart sound. Laboratory investigations were normal except low INR, hematocrit, and hemoglobin level (9 gm/L due to iron deficiency anemia). Transthoracic echocardiogram (TTE) and Transoesophageal echocardiogram (TEE) confirmed stuck aortic valve leaflet, with a high mean pressure gradient across prosthetic AV (34 mmHg). The mechanical mitral valve was working well. Fluoroscopy showed stuck one of the AV leaflets in a closed position. The treating physician decided to give her the chance for thrombolytic therapy. This case was treated with ultraslow thrombolytic therapy (Alteplase, 1 mg, every hour) with follow up transthoracic echocardiogram every 24 h to check the pressure gradient on the AV. She was young, asymptomatic, and hemodynamically stable. After 48 h of Alteplase, the stuck leaflet was released. The mean pressure gradient dropped to 16 mmHg. DISCUSSION: Ultraslow thrombolytic regimen advised to be tried in stuck mechanical valves and hemodynamically stable patients.

Tear of Posterior Mitral Valve Leaflet During MitraClip, Successful Bailout Using Vascular Plugs.

This case report describes a novel bailout technique (TAIBA technique) used in a MitraClip procedure that was complicated by a tear of the posterior mitral valve leaflet and caused torrential mitral regurgitation (MR). This is the first case report in which Amplatzer vascular plugs were used to treat severe MR after a tear in the posterior leaflet occurred during a MitraClip procedure. (Level of Difficulty: Advanced.).

Percutaneous Paravalvular Leak Closure Early Post-MV Replacement With Retrieval of Embolized Muscular VSD Device.

This report describes a case of paravalvular leak (PVL) closure 20 days after surgery that was complicated by an embolized 10-mm device in a patient who underwent redo PVL closure after 6 months. Waiting for 3 months postoperatively to close a PVL is recommended. If earlier leak closure is mandatory, accepting a suboptimal result with a moderate residual leak is advised. (Level of Difficulty: Intermediate.).

Percutaneous retrieval of an embolized gunshot bullet from right ventricle: a case report and review of literature.

BACKGROUND: Gunshots embolizing to the heart is a rare occurrence. We report a case of percutaneous retrieval of a gunshot bullet from the right ventricle (RV) cavity of a 40-year-old lady. To the best of our knowledge, this is the first case to be reported with a right supraclavicular inlet of the bullet and successful percutaneous retrieval using a snare from the RV cavity. CASE SUMMARY: A 40-year-old female patient was referred to our cardiac centre from a general hospital with a gunshot injury 8 days prior. On arrival, she was haemodynamically stable, there was an inlet wound at the right supraclavicular area. Transthoracic echocardiography revealed the bullet in the RV cavity. Under conscious sedation, right femoral vein access succeeded to retrieve the shot from the RV to the groin. The bullet slipped out and resnared from the right internal iliac vein and came out safely from the right femoral vein through the 24-Fr sheath. The vein was closed using a figure of 8 suture. The patient discharged home after 2 days. DISCUSSION: Bullet emboli to the heart are rare, endovascular retrieval of a bullet from the right ventricular cavity is feasible and relatively safe; however, more research is required. Echocardiography during the procedure is strongly recommended to early detect any complications. Accurate use of available tools such as X-ray, echocardiography, computed tomography, and fluoroscopy is a must for precise diagnosis.

Treatment of severe aortic stenosis and left ventricular outflow tract mass with transcutaneous aortic valve implantation: a case report.

BACKGROUND: Percutaneous implantation of aortic valve for severe aortic stenosis (AS) in the presence of pedunculated mobile left ventricular outflow tract (LVOT) mass not reported before. In this case report, we address the feasibility of this procedure. CASE SUMMARY: An 80-year-old patient who presented with presyncope, transthoracic echocardiogram (TTE), and transoesophageal echocardiography (TOE) revealed severe calcific AS and LVOT mass measuring 2.1*1.5 cm. The patient was turned down for surgery. It was decided that transcatheter aortic valve implantation (TAVI) be performed because the valve compresses the mass against the proximal part of the interventricular septum. The mass peduncle was 1.4 cm, and it was 4 mm away from the annulus. This meant the valve was needed to be deployed 18 mm below the annulus to cover the mass completely. Gentle manipulation and direct valve deployment without preballoon dilation to decrease the possibility of fragment embolization were necessary. Self-expandable core valve deployed as low as possible, after initial deployment, the distance of LVOT covered by the valve measured by TOE 1.66 cm, the whole mass was covered, then the valve was fully deployed. The patient was extubated in the catheterization room; there was no clinical evidence of embolization. The patient was discharged home after 2 days. A follow-up TTE after 6 months showed a well-functioning valve and the LVOT mass then disappeared. DISCUSSION: Pedunculated LVOT mass should be resected surgically. In high-risk surgical patients, direct TAVI to compress the mass is feasible in experienced canters. The safety issues need more research and more cases to judge. Transoesophageal echocardiography during the procedure is mandatory to guide the valve position.

Isolated adult congenital uni-leaflet severe mitral valve stenosis, a case report, and review of literature.

Reported cases of uni-leaflet mitral valve (MV) were related to the absence or dysplasia of the posterior mitral leaflet with ample anterior mitral leaflet. We present here a new entity of uni-leaflet MV where the MV appears as a membrane-like structure with a single slit-like orifice at its lateral part with no commissures. CASE REPORT: Continuous Doppler flow revealed a mean pressure gradient of 19 mmHg across the mitral valve indicating severe mitral stenosis. In 3D images from the left atrial view, the MV appeared like a membrane with a single orifice in its lateral part toward the left atrial appendage, the area of this orifice by 3D was 0.52 cm2, there were no commissures or even any residual lines at the site where commissures should be. The diagnosis of congenital severe mitral stenosis due to acommissural MV was confirmed. During surgery, the surgical appearance of the MV confirmed our diagnosis by 3D. CONCLUSION: Isolated congenital severe mitral stenosis presenting in adulthood is rare, uni-leaflet MV as a cause is only reported in a few cases. MV replacement is usually indicated due to the abnormal anatomy of MV leaflets and the subvalvular apparatus..