This article has been
cited by other articles in ScienceCentral.
A 80-year-old female patient presented with dyspnea intractable to medical therapy. She received surgical mitral valve replacement with Hancock II (Medtronic, Minneapolis, MN, USA) (
Figure 1) 27 mm bioprosthetic valve 11 years ago due to severe rheumatic mitral stenosis. Other comorbidities included atrial fibrillation, stroke, and restrictive lung disease. The echocardiography showed a prolapse of bioprosthetic mitral valve posterior leaflet with severe eccentric mitral regurgitation (MR) accompanied by severe resting pulmonary hypertension. The multi-detector computed tomography (MDCT) showed the degenerative change of mitral bioprosthetic valve with posterior leaflet prolapse.
Multi-disciplinary Heart team determined to undergo transcatheter mitral valve-in-valve replacement due to high surgical risk. Based on the MDCT analysis showing 460 mm
2 of bioprosthetic valve area, we selected the SAPIEN 3 (Edwards Lifesciences, Irvine, CA, USA) 26 mm transcatheter heart valve with the nominal size (519 mm
2), which achieved 13% area over-sizing. After the transseptal puncture, the atrial septum was dilated with a 10×40 mm balloon catheter (
Figure 2A). A small-curve Safari wire (Boston Scientific, Marlborough, MA, USA) was placed in the left ventricle. The SAPIEN 3 26 mm transcatheter heart valve was delivered into the bioprosthetic mitral valve (
Figure 2B) and deployed under rapid ventricular pacing (
Figure 2C). Left ventriculogram showed trivial MR without acute complications (
Figure 2D). Fluoroscopy showed that about 20% of the prosthesis was placed on the atrial side of the sewing ring (
Figure 3). Patient's symptoms subsequently improved and echocardiography showed trivial MR with mild resting pulmonary hypertension (
Supplementary Videos 1,
2,
3,
4).
Bioprosthetic mitral valve dysfunction requiring re-operation was about 40% after 15 years following surgical mitral valve replacement.
1) Reoperation is considered a high-risk procedure, particularly in elderly patients with multiple comorbidities.
2) Transseptal transcatheter mitral valve-in-valve replacement is a promising treatment strategy for those patients with excellent procedural success and acceptable long-term outcomes.
3)4)