Elvis Brscic

Elvis Brscic Responsabile Unità Operativa di Cardiologia ed Emodinamica presso Humanitas Gavazzeni di Bergamo

03/07/2026

A kamikaze mitral valve in valve procedure with a planned “bail-out strategy”.

A 79-year-old woman with a degenerated 27-mm Carpentier-Edwards Perimount mitral bioprosthesis presented with acute decompensated heart failure due to very severe bioprosthetic mitral stenosis (mean gradient more than 30 mmHg in acute phase, 18 mmHg after iv therapy) in non dilated LV with preserved ejection fraction. Given prohibitive surgical risk, transeptal valve-in-valve TMVR with a 26-mm balloon-expandable SAPIEN valve was planned. CT scan analysis demonstrated a markedly unfavorable mitro-aortic geometry, with an approximately right-angle relationship between the degenerated bioprosthesis and the LVOT. Valve simulation predicted a severely restricted neo-LVOT area. Transcatheter leaflet-modification techniques were not pursued because the principal determinant of LVOT obstruction was the unfavorable mitro-aortic geometry. Because of the clinical instability (the patient developed a cardiac arrest during CT scan) we decided to perform the intervention considering a strategy of preserving immediate access to the outflow tract to manage the predictable severe LVOT obstruction. The procedure was performed under general anesthesia, with fluoroscopic and TOE guidance. After balloon pre-dilatation, a 26 mm Sapien Edwards valve was implanted. Immediately after valve deployment, a severe invasive peak-to-peak LV-aortic gradient of 120 mmHg was recorded, consistent with acute LVOTO, resulting in hemodynamic instability. To relieve the obstruction, a combined transmitral-transaortic kissing-balloon inflation was first performed and then a single transaortic balloon was used to flare the ventricular frame of the valve decreasing suboptimally the gradient. So we decided to select and occlude with coils the first septal branch achieving significant reduction of the gradient with hemodynamic stabilization. Adjunctive medical therapy combined afterload augmentation with vasopressors and high-dose beta-blockade, contributed to hemodynamic recovery. The post-procedural course was good and the patient was discharged after 5 days. The 3 month follow-up confirm the good result of the VIV with a moderate LVOT gradient. Thanks to all guys of the Gavazzeni CathLab and to Edwards for the support in this very complex procedure.

01/04/2026

Extremely Complex Valve in Ring (VIR) procedure: effective use of gooseneck snare catheter for successfully shift to a Valve in Valve in Ring procedure (VVIR).

A patient with severe mitral regurgitation (MR) in previous surgical annuloplasty with a complete semirigid ring was scheduled for a procedure of valve in ring with a balloon expandable device. The native valve showed significant degeneration with flail and partial rupture of the anterior leaflet. The CT excluded risk of LVOT obstruction. After transeptal puncture and septoplasty the prosthesis was delivered in rapid pacing. The immediate result showed significant residual MR because of limited pop up and tilting of the device and the interference of native rupture leaflet on the opening movement of the prosthesis leaflet. The prosthesis was overstretched with a balloon but the result was really bad with worsening of MR, tilt effect and instability of the prosthesis. So we decided to delivere a second device for a VVIR procedure. In order to avoid the really high risk of embolization of the first device during the crossing a gooseneck snare catheter was used from controlateral femoral approach to modify the landing angle of the catether. The strategy was successful with an effective release and complete resolution of MR. Thanks to all guys of Gavazzeni cathlab for the great job and support.

06/03/2026

A male patient with severe degenerative MR was scheduled for Mitraclip procedure. The septum anatomy was unfavorable because of the limited width of fossa ovalis (only 6 mm), the limited height of the superior border (3.6 cm) and the presence of significant thickening of the superior and inferior part of the septum (approximately 9 mm). Many attempts of transeptal puncture with traditional approach were performed, but because of the septum thickeness the needle always jumped too low. So we decided to change strategy and puncture the septum from down to top using an Agilis Steerable Introducer, to direct to the superior border of the fossa ovalis the rigid part of 0.032 wire that was electrified for crossing the septum. Then through 0.018 wire an MP catheter was positioned in the upper pulmonary vein and by an 0.035 wire a septoplasty with 4.0 e 12.0 mm balloons were performed to make easier the positioning of the delivery system. After this, 2 XTW clips were successfully implanted.

Thanks to all guys of Humanitas Gavazzeni e Castelli cathlab and to Abbott for the support.

05/11/2024

Impianto percutaneo di Anello Mitralico AMEND: una nuova opzione per il trattamento dell’IM funzionale.

Un paziente anziano con insufficienza mitralica funzionale, pregresso scompenso cardiaco ed elevato rischio chirurgico, è stato sottoposto presso Humanitas Gavazzeni e Castelli di Bergamo a trattamento mediante impianto percutaneo di anello protesico mitralico 38 mm della . Procedura complessa ma efficace ed entusiasmante che apre nuovi scenari sulle opzioni di cura non chirurgica della patologia mitralica. Ringrazio tutto il personale del laboratorio di emodinamica del Gavazzeni, la Dott.ssa Alessia Azzano e il Dr. Andrea Cascella che hanno collaborato alla procedura. Un speciale ringraziamento va a tutta l’equipe della Valcare e soprattutto a David Meerkin, Nadav Yellin e Mauro Rossi per il superlativo supporto.
Percutaneous Anuloplasty with AMEND Ring: a new option for Functional Mitral Regurgitation therapy.

An elderly patient with significant MR, prior heart failure and very high surgical risk was effectively treated in Humanitas Gavazzeni Bergamo Hospital with a percutaneous implant of AMEND 38 mm Ring of Valcare. A complex but exciting procedure with a new non surgical device dedicated to treatment of secondary mitral regurgitation. Thanks to all guys of Gavazzeni CathLab Team. Thanks to D.ssa Alessia Azzano and Andrea Cascella who collaborated with me. And a special thanks to David Meerkin, Nadav Yellin, Mauro Rossi and all guys of Valcare Team for their incredible support.

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