ECMO Supported TMVR Valve In Ring and Large Paravalvular Leak Closure in a Critically Ill Patient

This video presents a complex and high-risk case of a 56-year-old male with severe comorbidities, including chronic kidney disease (CKD), coronary artery disease (CAD), antiphospholipid antibody syndrome (APLA), and prior mitral valve repair. The patient presented with acute decompensated heart failure (ADHF), severe mitral regurgitation (MR), and para-valvular leak (PVL), necessitating a multidisciplinary and innovative approach.

Case Overview:
Patient Background:

CKD on maintenance hemodialysis.
CAD with prior inferior wall myocardial infarction (IWMI).
APLA syndrome with a history of axillary artery and cortical vein thrombosis.
Severe MR post-chordal rupture, managed surgically with CABG and mitral valve repair using a rigid saddle ring.
Presentation at Admission:

Severe MR and large PVL (25x12mm).
Hemodynamic instability with severe pulmonary arterial hypertension (PAH) and RV dysfunction.
Symptoms: NYHA Class IV dyspnea, orthopnea, anasarca, and worsening renal function.
Challenges Identified:
Prohibitive surgical risk due to high STS and EuroSCORE, severe PAH, and RV dysfunction.
Rigid saddle ring posing technical challenges for TMVR due to lack of conformability and risk of valve dislodgement or residual PVL.
Large PVL requiring complex closure with two AVP II plugs.
Heart Team Strategy:
Given the high procedural risk, a decision was made to proceed with TMVR and PVL closure under prophylactic ECMO support to stabilize hemodynamics.

Procedural Details:
ECMO Support: Prophylactic percutaneous ECMO (19F arterial, 21F venous cannulas) for hemodynamic stability.
TMVR Technique:
Transseptal puncture guided by TEE.
Gradual inflation of the transcatheter valve within the rigid saddle ring under rapid pacing, ensuring optimal positioning.
PVL Closure:
Placement of two AVP II plugs under TEE guidance.
Overcame technical challenges during simultaneous deployment due to wire displacement.
Access Closure: Successful on-table decannulation with Perclose for ECMO cannula sites.
Post-Procedural Outcome:
Immediate stabilization with no significant mitral regurgitation and mild residual PVL.
Gradual recovery with improved cardiac function: LVEF 60%, RVSP 50mmHg.
Patient discharged in improved condition with NYHA Class II symptoms.
At 3-week follow-up: Marked symptomatic improvement and sustained clinical stability.
Key Takeaways:
This case exemplifies the critical role of:

Multidisciplinary collaboration in managing high-risk cardiac cases.
Prophylactic ECMO support to ensure procedural safety in unstable patients.
Innovative strategies to address technical challenges in transcatheter interventions.
The successful outcome underscores the importance of leveraging advanced interventional techniques to manage patients previously deemed inoperable.

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#Cardiology #TMVR #ECMO #HeartFailureManagement #AdvancedCardiacCare #HeartTeam #PVLClosure #MitralValveReplacement