Redo Mitral Valve Replacement After Valve-in-Valve Transcatheter Mitral Valve Replacement

Abstract

The rising preference for percutaneous mitral valve-in-valve replacement (ViV TMVR) over redo surgical mitral valve replacement (MVR) is primarily due to its reduced bleeding risk. This report details a bloodless redo MVR performed for mitral stenosis post-ViV TMVR. We present detailed intraoperative findings, including images of the extracted bioprosthetic valves and cardiac anatomy, providing valuable insights into the surgical complexities encountered. The case underscores the importance of meticulous planning and execution in redo MVR, especially in patients with a history of multiple valve interventions. Additionally, this report discusses the potential complications associated with ViV TMVR, contributing to the evolving understanding of this procedure's long-term outcomes. Our findings highlight the need for careful consideration of patient-specific factors and the inherent risks of redo valve surgeries, aiming to improve patient outcomes in complex cardiac cases.

Keywords: aortic valve surgery; bloodless approach; surgical mitral valve replacement; trans-catheter aortic valve replacement; transcatheter mitral valve-in-valve replacement.

Figure 1. Preoperative echocardiographic depiction of the mitral valve.

The Sapien 3 Ultra valve in the mitral position demonstrates preserved leaflet excursion. The yellow arrows and lines show fully opened mitral valve leaflets.

Figure 2. Preoperative echocardiographic depiction of the aortic valve.

Preoperative echocardiographic imaging of the aortic valve reveals a trileaflet structure. The echocardiogram shows no significant evidence of aortic stenosis or aortic regurgitation.

Figure 3. Excised Sapien 3 Ultra mitral valve.

Upon examination, there was no evidence of vegetation or pannus formation. Furthermore, the Sapien 3 Ultra valve remained intact, with its leaflets (indicated by the black line) demonstrating appropriate opening and closing dynamics.

Figure 4. Examination of the non-coronary cusp and mitral annulus post-extraction of the Sapien 3 Ultra valve.

The metallic framework of the Sapien valve exhibited robust adhesion to both the non-coronary and left-coronary cusps within the aortic valve and its annulus. Meticulous dissection was employed to separate them; however, partial resection of the aortic valve was necessitated.

Figure 5. Pathological findings in the papillary muscle.

The papillary muscle presented with pronounced calcification and thickening. Concurrently, the chordae exhibited sclerotic changes. These alterations contributed to the outflow obstruction observed in the preceding prosthetic mitral valves, resulting in mitral stenosis (MS) despite the preservation of normal leaflet mobility. A resection was performed on these affected papillary muscles and chordae.