Introduction: 83 year old female who presents with heart failure exacerbation due to severe bio prosthetic mitral valve dysfunction. Past Medical History: CHF, paroxysmal atrial fibrillation, CKD Stag..
Introduction: 83 year old female who presents with heart failure exacerbation due to severe bio prosthetic mitral valve dysfunction. Past Medical History: CHF, paroxysmal atrial fibrillation, CKD Stage III, MVR with St. Jude bio prosthetic valve, Maze procedure, left atrial appendage exclusion, and PFO closure. Why TMVR: Due to her frailty and co morbidities, she was deemed to not be a surgical candidate. TMVR was attempted. Case Presentation: General anesthesia, OETT, TEE guidance, invasive monitoring, and a sentinel cerebral protection device. During deployment the valve embolized into the LV. The embolized valve was snared and multiple attempts were made unsuccessfully to retrieve the embolized valve percutaneously with balloon dilation. Patient emergently transferred to the OR for retrieval of the mitral valve prosthesis from the LV and subsequent MVR with the Edwards Sapien 3 26 mm valve via median sternotomy, and cardiopulmonary bypass. Intraop was uneventful and she was transferred to CVICU for recovery on minimal vasopressor support. Patient did not wake up post operatively and was sent for CT head and CT angiogram head/neck. Complete occlusion of the right MCA with extensive infarct throughout the right MCA distribution and acute infarctions throughout the cerebellar hemispheres and left parietal temporal lobe were found suggestive of embolic stroke. After discussion comfort care was initiated and support was withdrawn leading to demise of the patient. TMVR is a less invasive alternative in patients with high or prohibitive surgical risk with high rate of successful valve implantation and excellent hemodynamic results. However, periprocedural complications and all cause mortality are relatively high. Malposition and migration are common, embolization of the valve is a rare but devastating complication. Management includes percutaneous retrieval, may be more challenging than embolized TAVI. Surgical management is often the only option. The embolized mitral valve may be a source of thromboembolism as highlighted here. Management of these patients involves paying meticulous attention to formation of a thrombus and consideration for utilizing a cerebral protection device.