Transcatheter mitral valve-in-valve implantation using a transseptal approach

Transcatheter mitral valve-in-valve intervention (TMVI) is an alternative mode of treatment to re-do surgery for bioprosthetic valve failure. Although transapical access represents the shortest route to deliver the new bioprosthesis in the mitral position, currently the transseptal route is becoming more popular [1, 2]. We present the first case in Poland of TMVI using transseptal access.
A 69-year-old female patient who underwent surgical mitral valve replacement with an Epic 31 mm (Abbot) valve, after 2 ischemic strokes with pulmonary hypertension and chronic kidney disease stage 4 (EuroSCORE II 9.8%), developed dyspnea 3 years following surgery (NYHA class III). Echocardiographic examination revealed signs of severe stenosis and mild insufficiency of the Epic valve. After discussion at the heart team meeting, due to high risk of a re-do operation the patient was referred for TMVI.
Based on the internal lumen diameter of the Epic valve the suggested valve size should be 29 mm (Figure 1 A), but cardiac computed tomography (CCT) revealed extensive hypodense pannus formation with mean inner lumen diameter of 21 mm (Figure 1 B). Because of this appearance it was agreed to perform balloon sizing of the degenerated bioprosthesis with a 22 mm balloon catheter. The patient was screened for possible left ventricular outflow tract (LVOT) obstruction by means of neo-LVOT calculation and aorto-mitral angulation, showing no or little risk of obstruction (Figures 1 C–E) [3, 4].
The procedure was performed via the transvenous route in general anesthesia under transesophageal echocardiography (TEE) guidance. After puncture of the interatrial septum in postero-inferior location and crossing through the degenerated valve into the left ventricle, dilatation of the intra septal channel was performed with a 12 × 40 mm peripheral balloon catheter. Predilation with a 22 mm balloon catheter was performed and upon inflation a clear waist was visible (Figure 2 A); therefore a 26 mm Sapien 3 (Edwards Lifesciences) valve was chosen. Despite the previous dilatation of the intra-septal channel the crossing with the delivery system showed some difficulty, but after changing to a Lunderquist Extra Stiff guidewire and some mild dilatation of the distal part of the Edwards balloon it was possible to obtain correct positioning (Figure 2 B). During rapid pacing the valve was implanted in a 20%/80% (atrium/ventricle) depth ratio and afterwards postdilated distally...


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