Transcatheter Mitral Valve Replacement in Failed Bioprosthetic Surgical Valves and Surgical Annuloplasty Rings

Transfemoral Transseptal Mitral Valve-in-Valve-in-Valve of a Degenerated Transcatheter in Surgical Bioprosthesis

OBJECTIVE

The authors describe a transcatheter mitral valve-in-valve-in-valve (VIVIV) for the correction of a degenerated transcatheter in a surgical bioprosthesis, a challenging interventional scenario that will be increasingly frequent in the near future.

KEY STEPS

The key steps taken were as follows: preprocedural planning integrating data from transesophageal echocardiogram, cardiac computed tomography, and 3mensio reconstruction (Pie Medical Imaging); transfemoral transseptal VIVIV performed with EchoNavigator system (Philips) guidance; Sapien Ultra 3 26-mm valve (Edwards Lifesciences) delivered with buddy balloon maneuvers to uncage the valve from the atrial struts of the previously implanted valve; and atrial septal defect occlusion with the Amplatzer ASO 24 mm (Abbott Cardiovascular).

POTENTIAL PITFALLS

The inability to advance the prosthesis into the ventricle, irreversible hemodynamic collapse, residual high transmitral mean gradient because of impingment of the 3 valves, residual paravalvular leaks, and left ventricular outflow tract obstruction.

TAKE-HOME MESSAGES

Mitral VIVIV procedures represent a viable option for patients with prohibitive surgical risk and a degenerated transcatheter in surgical bioprostheses. Success hinges on adequate preprocedural planning and a thorough understanding of bailout techniques to minimize failure and prevent major complications.

Postsurgical Transcatheter Mitral Valve Replacement

Reintervention is commonly required postsurgical mitral valve replacement (SMVR) or repair due to bioprosthetic valve and annuloplasty ring degeneration. However, redo SMVR is associated with a high risk of morbidity and mortality. Postsurgical transcatheter mitral valve replacement (TMVR) is a safe and less-invasive alternative that has repeatedly been shown to be associated with improved survival and lower rates of complications compared with redo SMVR. Comprehensive patient evaluation and thorough procedural planning are key to successful TMVR.