Transcatheter Mitral Valve-in-Valve Replacement

Figures

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  Figure 1. Initial Transthoracic and Transesophageal Echocardiography (A) Transthoracic measures of transmitral gradients (peak: 33.7 mm Hg, mean: 17.9 mm Hg) and mitral valve area estimated by pressure half-time (0.69 cm2). (B) Transesophageal measures of transmitral gradients (peak: 30 mm Hg, mean: 18 mm Hg). (C) Transesophageal view of the mitral bioprosthesis with thickened leaflets (arrow).

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  Figure 2. Tomographic Analysis of Risk Factors for LVOT Obstruction (A and B) Two-dimensional analysis with projection of new mitral valve shows invasion into the LVOT and aortomitral angle of 62°. (C) Volume-rendered imaging with projection of the new mitral valve shows invasion into the LVOT. (D) Cross-sectional imaging of the LVOT shows the projected position of the new mitral valve and measurement of the neo-LVOT of 146.6 mm2. LVOT = left ventricular outflow tract.

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  Figure 3. Bovine Aortic Arch Volume-rendered imaging of the patient's bovine aortic arch. (A) Innominate artery. (B) Right subclavian artery. (C) Right carotid artery. (D) Left carotid artery with anomalous origin from the innominate artery. (E) Left subclavian artery.

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  Figure 4. Schematic Representation of the BATMAN Technique (A) Postprocedural LVOT obstruction in the absence of BATMAN. The obstruction is caused by the fixed open position of the surgical anterior leaflet after transcatheter valve deployment. Arrow denotes fixed open position of the mitral bioprosthesis anterior leaflet. Asterisk denotes obstructed LVOT. (B) Superior view at the level of the atrioventricular valves. Asterisk denotes site of perforation located at the basal portion of the anterior leaflet of the mitral bioprosthesis. (C) Sequential balloon dilatations through the basal portion of the anterior leaflet of the mitral bioprosthesis. Arrow denotes balloon dilatation. (D) Outcome after M-ViV with the BATMAN technique, demonstrating no LVOT obstruction. Double asterisk denotes nonobstructed LVOT. Ao = aorta; AV = aortic valve; EGW = electrified guidewire; LA = left atrium; LCA = left coronary artery; LV = left ventricle; MBP = mitral bioprosthesis; M-ViV = mitral valve-in-valve; PV = pulmonary valve; RCA = right coronary artery; TV = tricuspid valve.

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  Figure 5. Left Atrial Appendage Thrombus (A and B) Two-dimensional transesophageal echocardiographic imaging of the left atrial appendage thrombus (arrows). (C) Thrombotic material obtained by aspiration from the left atrial appendage.

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  Figure 6. Anterior Mitral Leaflet Perforation System and Balloon Dilation Sequence (A) Perforation system: 8-F deflectable sheath (1), 5-F multipurpose catheter (2), Rubicon microcatheter (3), electrified Astato guidewire (4). (B) 2.0-mm coronary balloon dilatation. (C) 4.0-mm coronary balloon dilatation. (D) 10 × 80 mm peripheral balloon dilatation and concomitant septostomy (arrow). (E) 26-mm Atlas Gold valvuloplasty balloon dilatation.

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  Figure 7. Final Result After Mitral Valve-in-Valve Implantation (A) Fluoroscopic view of the implanted valve. (B) Transesophageal echocardiographic 2D view of the implanted valve. (C) Transmitral gradients (mean: 3 mm Hg, peak: 9 mm Hg). (D) Transesophageal echocardiographic 3D reconstruction of the implanted valve. 2D = two-dimensional; 3D = three-dimensional.

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  Figure 8. Retrieved Thrombotic Debris From the Sentinel Cerebral Protection Device (A) Innominate artery filter. (B) Left carotid artery filter. Arrows denote retrieved material.

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  Visual Summary. Strategies to Overcome Multiple Treatment Obstacles in a Patient With a Degenerated Mitral Bioprosthesis and Acute Heart Failure The figure outlines the key challenges encountered during treatment planning and the stepwise strategies applied to address each obstacle, enabling a feasible therapeutic approach. CEPD = cerebral embolic protection device; LAA = left atrial appendage; LVOT = left ventricular outflow tract; M-ViV = mitral valve-in-valve.