Transcatheter transapical valve-in-valve implantation for degenerated mitral bioprosthesis

A 76-year-old woman with a history of aortic and mitral valve (Mosaic 19 mm; Hancock II 25 mm bioprosthesis, Medtronic Inc., Minneapolis, Minnesota) replacement and former coronary artery bypass grafting in 2010 (left internal mammary artery-left anterior descending artery (LIMA-LAD), aorta-obtuse marginal coronary artery (Ao-OM)) was admitted to our hospital with recurrent pulmonary edema. Her past medical history consisted of arterial hypertension, diabetes, renal insufficiency with an estimated glomerular filtration rate of 51 ml/min and previous stroke. Transthoracic (TTE) and transesophageal (TEE) echocardiography revealed a degenerated bioprosthesis in the mitral position with severe eccentric regurgitation (Figure 1 A); the aortic bioprosthesis was of normal function; moderate left ventricular systolic dysfunction was observed (LVEF 45%). In coronary angiography patent LIMA-LAD and Ao-OM grafts were found. Taking into account the high surgical risk, the Heart Team decided to perform a mitral transcatheter valve-in-valve (TVIV) procedure. Mitral TVIV implantation was conducted under general anesthesia via the transapical approach. In the pre-procedural period the mitral bioprosthesis was also evaluated and sized in multi-slice computed tomography (MSCT) (Figure 1 B). According to the manufacturer’s specifications with regard to the inner diameter of the Hancock II 25 mm bioprosthesis and the data obtained from MSCT, a 23 mm balloon-expandable SAPIEN XT valve (Edwards Lifesciences, Irvine, California) was slowly deployed extending 4 mm atrially relatively to the mitral radiopaque sewing ring during a short period of rapid pacing (Figure 1 C). Peri-procedural TEE and TTE before discharge revealed good implant stability and no residual mitral regurgitation (Figure 1 D). The further in-hospital course was uneventful, and the patient was discharged on the seventh day after the procedure. Mitral TVIV implantation is an emerging clinically effective technique for eligible patients with a degenerated mitral bioprostheses [1]. The access to the mitral valve can be antegrade through the venous system with a transseptal approach or retrograde, through the left ventricle apex via a mini left thoracotomy. The first approach was found technically challenging, with difficulty in achieving coaxial alignment of the valve to the mitral prosthesis for optimal implantation [2]. The transapical approach provides the shortest and co-axial access to the mitral valve....


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