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Abstract

Background: Transcatheter mitral valve replacement has emerged as an alternative to surgery in high and prohibitive risk patients for severe mitral valve regurgitation. The AltaValve has a better safety profile as it has an atrial fixation method that minimizes the risk of LVOT obstruction. We present a challenging case where despite successful placement of 4C medical’s Altavalve, patient developed a significant left to right shunt requiring treatment.
Case: A 79 years old female, status post CABGx3 and multivessel PCI, paroxysmal atrial fibrillation, Diabetes mellitus type 2, hypertension, hyperlipidemia, peripheral artery disease, had severe symptomatic degenerative mitral valve regurgitation for which MitraClip was attempted but aborted because of increased intraoperative gradients. As part of a phase 1 trial, she underwent 4C medical’s AltaValve placement due to high surgical risk after which she developed perivalvular leak on lateral, anterior and inferomedial aspect that reduced to mild after pulling the valve up with snare and anticoagulation reversal (as ACT was above 350). On 2nd day she developed new onset shortness of breath and follow up TEE showed normal functioning Altavalve with mean gradient of 2.5mmHg, trace perivalvular leak, severe tricuspid regurgitation and a 0.7cm iatrogenic bidirectional inter-arterial shunt with Qp/Qs of 1.7/1.0, requiring a 14mm Amplatzer ASD closure device. Her final echo report showed mean gradient of 2mmHg, trace paravalvular leak, Amplatzer device well seated with no significant shunt and moderate tricuspid regurgitation. On last follow up, her shortness of breath has improved.
Conclusion: This case illustrates the challenges of transcatheter mitral valve replacement and the need for vigilant post-procedural monitoring. Despite successful AltaValve placement for severe mitral regurgitation, the development of a left-to-right interatrial shunt requiring timely recognition and closure to improved patient outcomes emphasizing the importance of individualized management, complication awareness, and post-procedure surveillance to enhance the safety and effectiveness of TMVR.