Transseptal Mitral Valve-in-Valve Implantation Using an Arteriovenous Loop

Figures

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  Visual Summary. Graphic Representation of Valvular History, ViV Implantation, and Follow-Up ViV = valve-in-valve.

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  Figure 1. Transthoracic Echocardiography and Transesophageal Echocardiography Showing Degenerated Mitral Bioprosthesis (A) Massive biatrial enlargement. (B and C) Mitral bioprosthesis flail (arrow) with severe regurgitation on transthoracic echocardiography. (D) Mean transvalvular gradient of 9 mm Hg. (E and F) Bioprosthetic leaflet tear and prolapse (arrow) with severe intraprosthetic regurgitation on transesophageal echocardiography.

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  Figure 2. Procedural Challenge (A) Significantly increased cardiothoracic ratio. (B) Preprocedural computed tomography angiography showing the massive atrium. (C and D) True internal diameter of the bioprosthesis measured by computed tomography angiography and the baseline data. (E) Neo–left ventricular outflow tract area. (F) Septal-annular angle. (G) Angle between the inferior vena cava–atrial septum line and the mitral valve–left ventricular apex axis. (H) Angle between the inferior vena cava–superior vena cava axis and the mitral annulus–left ventricular apex line.

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  Figure 3. Mitral Valve-in-Valve Implantation (A) Final puncture height. (B) Left ventriculography showing massive mitral regurgitation. (C) Predilation using a 16-mm balloon with an arteriovenous loop. (D) Valve system advancing through the bioprosthetic valve. (E) SAPIEN 3 valve successfully deployed under rapid pacing. (F) Left ventriculography showing the well-deployed SAPIEN 3 valve with mild paravalvular leak.

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  Figure 4. Final Result (A) Mild paravalvular leak on postdeployment transesophageal echocardiography. (B) Mean left ventricular outflow tract gradient of 9 mm Hg on postprocedural transthoracic echocardiography.