Team replaces mitral valve and implants LVAD
Harrington Heart & Vascular Institute Innovations - Summer 2017
Monique Robinson, MD, PhD
Cardiologist, UH Cleveland Medical Center, Clinical Assistant Professor of Medicine, Case Western Reserve University School of Medicine
Guilherme Oliveira, MD
Director, Advanced Heart Failure and Transplant Center, UH Cleveland Medical Center, Clinical Associate Professor of Medicine, Case Western Reserve University School of Medicine
A team of heart failure specialists, cardiac surgeons and interventional cardiologists from University Hospitals Cleveland Medical Center recently performed the first-ever successful procedure combining transcatheter mitral valve replacement with placement of a left ventricular assist device (LVAD). The case is described in a recent issue of Circulation: Heart Failure.
The patient was a 67-year-old man with ischemic cardiomyopathy, stage D heart failure and mitral stenosis that had developed in his bioprosthetic replacement valve. The patient also had previously undergone a six-vessel coronary artery bypass graft procedure.
“By the time he was referred to us, he had been hospitalized multiple times in the preceding six months with acutely decompensated heart failure, severe ascites and malnutrition and was maintained on home inotropic therapy,” says UH heart failure specialist Monique Robinson MD, PhD, who was part of the treating team.
To stabilize the patient before making a final decision about their course of action, the UH team implanted a temporary percutaneous LVAD. The patient was not deemed eligible for heart transplantation because of his poor renal function, poor nutritional status and elevated pulmonary artery pressures. After 10 days of therapy with the temporary LVAD, the patient’s renal function normalized and he was up and walking.
“Given the clinical improvement with better forward flow, durable LVAD placement was planned as destination therapy with concomitant mitral valve and tricuspid valve repair,” says Guilherme Oliveira, MD, Director of the Advanced Heart Failure and Transplantation Center at UH.
During the procedure, UH interventional cardiologist Guilherme Attizzani, MD, first deployed a SAPIEN XT transcatheter valve using a balloon catheter to maneuver it into the mitral position. This completed the mitral valve replacement portion of the procedure, taking less than a minute. UH cardiac surgeon Basar Sareyyupoglu, MD, then implanted the HeartMate II LVAD; a concomitant tricuspid valve ring repair was also performed through a right atriotomy.
“To implant the LVAD, you need to take a little bit of the core of the left ventricle,” Dr. Robinson explains. “They made that opening so they could see the mitral valve under direct visualization, then they used the catheter to place the valve in the mitral position, then they put the LVAD in.”
According to Dr. Robinson, the patient is now doing “phenomenally well.”
“For patients like this, we’ve proven that this combination procedure can safely be done,” she says. “That’s where medical innovation starts. It sets a precedent for other centers who have similarly unwell patients to consider a similar approach.”
“We took advantage of two existing techniques that had never been applied together,” adds Dr. Oliveira. “It reduced the risk to the patient. It had never been done before, and it worked. This could be a trend-setter to reduce the risks of LVAD implantation in future patients.”