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Case Reports
. 2023 Jan 12:24:e938415.
doi: 10.12659/AJCR.938415.

Challenging Case of Transcatheter Mitral Valve-in-Valve-in-Valve Replacement

Muhammad H Khan  1 , Nicholas L Biondi  2 , Shaheer Zulfiqar  2 , Imran Arif  2 , Manisha Das  2 , Mehak Budhiraja  1 , Wilbert S Aronow  3 , Rishi Sukhija  2 , Mehta Vimal  4
Affiliations
Case Reports

Challenging Case of Transcatheter Mitral Valve-in-Valve-in-Valve Replacement

Muhammad H Khan et al. Am J Case Rep. .

Abstract

BACKGROUND A 39-year-old man with a complex valvular history of recurrent methicillin-resistant Staphylococcus aureus endocarditis with 2 surgical mitral valve replacements (in 2016 and 2017) followed by transcatheter mitral valve replacement (in 2019) presented with orthopnea, paroxysmal nocturnal dyspnea, chest pain, cough, and progressively worsening dyspnea on exertion. CASE REPORT Extensive workup was performed, including transesophageal echocardiogram, which revealed a malfunctioning, severely stenotic bioprosthetic valve. Left and right heart catheterization revealed mild non-obstructive coronary artery disease and severe pulmonary hypertension. Given the patient's complex medical history, he was deemed to be at an elevated risk for repeat sternotomy and repeat valve replacement surgery. Therefore, he underwent a percutaneous transcatheter mitral valve replacement with a 26-mm SAPIEN 3 Edwards valve placed within the previous 29-mm SAPIEN valve. Post-procedural imaging revealed a well-placed valve with an improved mitral valve gradient. CONCLUSIONS This is one of the few rare cases of mitral valve-in-valve via a transcatheter mitral valve replacement approach with successful deployment of a SAPIEN 3 tissue heart valve. The patient experienced significant reversal of heart failure symptoms and improved exertional tolerance following deployment of the valve and was eventually discharged home in a stable condition.

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Conflict of interest statement

Conflict of interest: None declared

Figures

Figure 1.
Figure 1.
Pre-procedure transesophageal echocardiogram (TEE): Continuous wave inflow Doppler of mitral valve on TEE showing severe stenosis of bioprosthetic mitral valve with a mean gradiant of 11.72 mmHg.
Figure 2.
Figure 2.
Three-dimensional image of severely stenotic bioprosthetic mitral valve on pre-deployment transesophageal echocardiogram: Surgeon’s view from the left atrium showing severe leaflet restriction with severely reduced valve opening.
Figure 3.
Figure 3.
Computed tomography assessment of mitral valve: To assess annular size and to determine appropriate size of the new valve.
Figure 4.
Figure 4.
Computed tomography assessment of neo left ventricular outflow tract (LVOT): Shows average area of 26.44 mm after valve implantation, which would be low risk for LVOT obstruction.
Figure 5.
Figure 5.
Prior to dilation: Fluoroscopy shows overlapping previously deployed valve stent struts.
Figure 6.
Figure 6.
Persisting waist: Fluoroscopy shows significant waist after initial balloon inflation.
Figure 7.
Figure 7.
After dilation: Fluoroscopy shows resolution of waist and fracture of the stent struts after high pressure inflation of the balloon.
Figure 8.
Figure 8.
Three-dimensional image of bioprosthetic mitral valve on post-deployment transesophageal echocardiogram: Surgeon’s view showing successful placement of the new bioprosthetic mitral valve with full leaflet opening and improved valve area, as compared with Figure 2.
Figure 9.
Figure 9.
Post-procedure transesophageal echocardiogram: Continuous wave inflow Doppler of mitral valve post-deployment showing resolution of severe stenosis and an improved mean gradient of 4.16 mmHg.
See this image and copyright information in PMC

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