Transesophageal-echocardiography-guided one-stage TAVR + M-TEER credibly treated patients with severe double valve regurgitation: a case report
Case Report

Transesophageal-echocardiography-guided one-stage TAVR + M-TEER credibly treated patients with severe double valve regurgitation: a case report

Chunping Sun1 ORCID logo, Lai Wei2,3, Lili Dong3,4, Peng Zhu1, Jun Lu1, Zezhou Xiao1, Shaoyi Zheng1

1Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; 2Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China; 3Shanghai Institute of Cardiovascular Disease, Shanghai, China; 4Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China

Contributions: (I) Conception and design: C Sun, S Zheng; (II) Administrative support: S Zheng; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: C Sun; (V) Data analysis and interpretation: S Zheng, L Wei, L Dong, C Sun; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Shaoyi Zheng, MD. Department of Cardiovascular Surgery, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Baiyun District, Guangzhou 510515, China. Email: zhsy@smu.edu.cn.

Background: There are few reports about the one-stage surgery of transcatheter aortic valve replacement (TAVR) + mitral valve transcatheter edge-to-edge repair (M-TEER) around the world. TAVR + M-TEER surgery is usually performed under the simultaneous guidance of digital subtraction angiography (DSA) and echocardiography. There is no report of TAVR surgery assisted only by echocardiography all over the world. This case shows a novel one-stage transesophageal echocardiography-guided TAVR + M-TEER surgery, which provides a new idea for minimally invasive therapy.

Case Description: A 75-year-old man with recurrent chest tightness was diagnosed with bicuspid aortic valve malformation and severe regurgitation of aortic and mitral valves. The symptom was not relieved by medications. After evaluation with transthoracic echocardiography and computerized tomography angiography (CTA) of the aorta, transapical TAVR and M-TEER were performed simultaneously with satisfied clinical results. The patient’s activity tolerance and cardiac function were improved.

Conclusions: In the past, this surgery needs to be performed in a specific operating room equipped with an X-ray machine, and there are many steps in the whole procedure that requires more medical staff. Transesophageal echocardiography-guided minimally invasive valvular surgery reduces the reliance on the hybrid operating room, mitigates the impact of radiation on physicians and patients, and also provides a treatment chance for gravidas with valvular disease.

Keywords: Transcatheter aortic valve replacement (TAVR); mitral valve transcatheter edge-to-edge repair (M-TEER); transesophageal echocardiography; case report


Received: 14 March 2024; Accepted: 13 September 2024; Published online: 06 November 2024.

doi: 10.21037/acr-24-71


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Key findings

• In this report, a novel one-stage transesophageal echocardiography-guided transcatheter aortic valve replacement (TAVR) + mitral valve transcatheter edge-to-edge repair (M-TEER) surgery is presented.

What is known and what is new?

• Several published studies have confirmed that all TAVR + M-TEER surgeries are performed under the guidance of digital subtraction angiography and echocardiography. However, there are no studies on TAVR surgery under echocardiography guidance alone all over the world.

• Transesophageal echocardiography-guided TAVR + M-TEER surgery is the first surgery in the world that reduces the reliance on hybrid operating rooms and mitigates the radiation damage to physicians and patients.

What is the implication, and what should change now?

• In the past, TAVR needs to be performed in a hybrid operating room equipped with an X-ray machine, and there are many steps in the whole procedure that requires more medical staff. Transesophageal echocardiography-guided minimally invasive valvular surgery reduces the reliance on the hybrid operating room, mitigates the impact of radiation on physicians and patients, and also provides a treatment chance for gravidas with valvular disease.


Introduction

Transcatheter aortic valve replacement (TAVR) has become a popular technique for its safety and efficacy, which can be used for the treatment of patients with severe aortic regurgitation (AR) or stenosis who have surgical contraindications or are at high risk. With the application of TAVR technology, the combined treatment of valvular diseases has attracted more and more attention. About 30% of patients receiving TAVR suffer from moderate to severe mitral regurgitation (1,2). We present this case in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-24-71/rc).


Case presentation

A male patient, 75 years old, with symptoms of chest tightness, shortness of breath, and edema of both lower limbs after exercise for more than 3 months, was classified as New York Heart Association (NYHA) functional class II–III. The left ventricle and left atrium were 52 and 54 mm in size, respectively. A grade 2/6 systolic murmur was audible at the apex of the heart, and a grade 2/6 diastolic murmur was audible in the auscultation area of aortic valve. The patient had bicuspid aortic valve malformation with severe regurgitation, and mitral valve A2 chordae rupture with severe regurgitation. Aortic computerized tomography angiography (CTA) requires evaluation of aortic valve, coronary artery and aorta, same as timeline.

Timeline

Day 1: aortic valvular leaflets were obviously calcified with severe regurgitation with an area of 9.88 cm2. The A2 chordae tendineae of mitral valve was ruptured with regurgitation with an area of 14.1 cm2.

Day 3: a type I bicuspid aortic valve was observed with an aortic valve ring diameter of approximately 27.5 mm (Figure 1A). The height of the left coronary artery ostium was 21.3 mm (Figure 1B) and that of the right coronary artery ostium was 14.5 mm (Figure 1C).

Figure 1 Transesophageal echocardiography guided TAVR. (A) Diameter of the aortic annulus. (B) Height of left coronary artery ostium. (C) Height of right coronary artery ostium. (D) Aortic valve regurgitation indicated by the blue arrow. (E) Guide wire crossing the valve indicated by the blue arrow. (F,G) Positioner crossing the valve, entering the corresponding sinus indicated by the blue arrows. (H) Lowering the valve to the annulus level indicated by the blue arrow. (I) Releasing the valve. (J) The shape and implant position of the artificial aortic valve. (K) Balloon expansion on the valve indicated by the blue arrow. (L) Smooth blood flow through the valve without regurgitation indicated by the blue arrow. TAVR, transcatheter aortic valve replacement.

Day 13: transapical TAVR (TA-TAVR) and mitral valve transcatheter edge-to-edge repair (M-TEER) were performed successively under the guidance of transesophageal echocardiography with general anesthesia.

Day 15: the patient was separated from the ventilator and treated with high-flow oxygen.

Day 18: the patient was transferred to a general ward.

Day 24: the patient was found to have a left-sided pleural effusion, which was considered to be a postoperative pleural effusion.

Day 30: the patient recovered well and was discharged from the hospital. After discharge, the patient received medications recommended by formal guidelines.

The patient had severe AR (Figure 1D) complicated by mitral regurgitation and was eligible for TA-TAVR. Therefore, after interdisciplinary collaborative evaluation by the relevant team of Nanfang Hospital, Southern Medical University, TA-TAVR and transapical transcatheter edge-to-edge repair (TA-TEER) at the same period were considered to be the best treatment options for the patient.

TAVR was performed firstly along with the MitraClip surgery after completing the relevant preoperative examinations on May 19, 2023. The patient was placed in a supine position and received general anesthesia with tracheal intubation. Under the monitoring of transthoracic echocardiography, the best intercostal approach was determined and marked. An intercostal space of about 6 cm was first marked in the left anterolateral direction, then the thoracic cavity was entered layer by layer to expose the pericardium, the best puncture point was determined again under the continuous monitoring of transesophageal ultrasound, and a double-layer purse-string suture was completed for use.

The trajectory from aortic valve to descending aorta was established under the guidance of long-axis and short-axis sections of mid-esophageal ultrasound, then the super-hard guide wire was exchanged (Figure 1E), and Suzhou Jiecheng J-Valve Implanter TA-29 mm (Suzhou, China) with CVM-AV (self-dilating interventional model aortic valve) 27 mm valve was delivered into the ascending aorta (Figure 1F) along the guide wire, and then the positioning key was released. The three positioning keys of the valve were retracted into the three valve sinuses (Figure 1G,1H), and the artificial valve was placed in the position of valve ring (Figure 1I) under esophageal ultrasound with complete release of the valve (Figure 1J). After withdrawing the delivery sheath, the 26# Numed (Hopkinton, USA) balloon was exchanged to expand the valve once under the condition of overspeed pacing (Figure 1K). The stent valve was placed in good shape with no obvious regurgitation and perivalvular leakage (Figure 1L) under esophageal ultrasound. Mitral valvular A2 chordae was ruptured with severe regurgitation (Figure 2A-2C). The apex-mitral to valve-left atrium orbit was established on the transection of mitral valve closure edge and left ventricular long axis in the middle esophagus. Then the sheath was guided to the left atrium and withdrawn from the valve-crossing device, and the delivery sheath was exchanged. The A2–P2 region was clamped using Shanghai Hanyu Medical valveclamp (VC-IIIf, Shanghai, China) mitral valve clamping system (Figure 2D) under the guidance of esophageal ultrasound. Esophageal ultrasound showed slight mitral regurgitation with a transvalvular pressure of 1 mmHg. The therapeutic effect was satisfactory.

Figure 2 Transesophageal echocardiography guided M-TEER. (A) Rupture of mitral valve A2 chorda indicated by the blue arrow. (B) Massive eccentric regurgitation of mitral valve and mitral valve color regurgitation indicated by the blue arrow. (C) Massive eccentric regurgitation of mitral valve by evaluation of another section, as indicated by the blue arrow. (D) Transesophageal echocardiography-guided clamping of mitral valve A2–P2, with blue arrows indicating no obvious regurgitation. M-TEER, mitral valve transcatheter edge-to-edge repair.

One month postoperatively, echocardiography showed a double-orifice mitral valve and a small amount of mitral regurgitation with an area of 2.6 cm2. After TAVR, the function of biological valve was basically normal with an average transvalvular pressure of 10 mmHg. There was no regurgitation signal around the valve, a small amount of diastolic regurgitation with an area of 2.6 cm2 and a small amount of tricuspid regurgitation with an area of 1.9 cm2 were observed. The left ventricular ejection fraction was 58%, and the left atrial anteroposterior diameter was 30 mm.

Three months postoperatively, echocardiography showed a double-orifice mitral valve and a small amount of mitral regurgitation with an area of 2.0 cm2 after TEER. After TAVR, the function of biological valve was basically normal with an average transvalvular pressure of 6 mmHg. There was no regurgitation signal around the valve, and a small amount of regurgitation could be seen in the diastolic valve. Tricuspid valve was similarly regurgitated.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.


Discussion

Aortic valve insufficiency is a common clinical aortic valve-related disease. The main causes are the primary diseases of aortic valve leaflets and the abnormal anatomical structure of aortic root or ascending aorta, among which the degeneration of aortic valve is a very important cause of AR. At the same time, AR is asymptomatic in the early stage. When clinical symptoms appear, AR has mostly entered the late stage, so the proportion of elderly AR patients is relatively large (3,4). For elderly patients with AR, surgical valve replacement is the best treatment option, but these patients often have poor basic conditions, common complications, surgical history and poor cardiac function that make it difficult for them to tolerate surgical blows. Without surgical treatment, the annual mortality rate is 10–20% (5). In recent years, TAVR has become a relatively safe and effective means to treat patients with severe AR or stenosis who have surgical contraindications or are at high risk (6). With the application of TAVR technology, the combined valvular disease has attracted more and more attention. Previous studies have found that moderate-to-severe mitral valve insufficiency is present in about 30% of patients receiving TAVR (1,2,7).

In this case, the patient suffered from valvular disease with clear surgical indications for TAVR and M-TEER treatment. After strict preoperative evaluation, the anatomical structure was suitable for TAVR and M-TEER, which became the best treatment options for this patient. The patient’s symptoms improved postoperatively, and echocardiography was performed 3 months after surgery. The function and structure of the biological valve were normal, and the mitral regurgitation was reduced. This case provides a new treatment and surgical scheme for elderly patients with combined valvular disease, severe AR and mitral regurgitation. At present, there are few reports about the simultaneous TAVR and M-TEER at home and abroad (8).


Conclusions

All TAVR + TEER surgeries have been performed under the guidance of digital subtraction angiography (DSA) and echocardiography. There is no precedent for a TAVR surgery under the guidance of echocardiography alone all over the world. In this case, echocardiography-guided one-stage TAVR combined with M-TEER surgery of double valve regurgitation and other valve interventions under the guidance of echocardiography alone can reduce the reliance on hybrid operating rooms and mitigate the radiation damage to physicians and patients. Randomized clinical trials with larger sample sizes and longer follow-up periods are still needed to confirm the safety and efficacy of the combined surgery and the appropriate timing of surgical intervention. It is believed that in the future, this technology can also provide services for more medical teams and bring better experiences to more patients.


Acknowledgments

Funding: This study was supported by National Natural Science Foundation of China (No. 8217027); Guangdong Provincial International Science and Technology Cooperation Project (No. 2022A0505050036); Guangdong Basic and Applied Basic Research Foundation (No. 2214050004117); and Guangzhou Key Research & Development Program (No. 202206011130280013).


Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://acr.amegroups.com/article/view/10.21037/acr-24-71/rc

Peer Review File: Available at https://acr.amegroups.com/article/view/10.21037/acr-24-71/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://acr.amegroups.com/article/view/10.21037/acr-24-71/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.


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doi: 10.21037/acr-24-71
Cite this article as: Sun C, Wei L, Dong L, Zhu P, Lu J, Xiao Z, Zheng S. Transesophageal-echocardiography-guided one-stage TAVR + M-TEER credibly treated patients with severe double valve regurgitation: a case report. AME Case Rep 2025;9:16.

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