Transcatheter Mitral Valve Replacement in Failed Mitral Bioprosthesis: Case Report

Figures

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  Figure 1. ECG on admission showing atrial fibrillation with an approximate ventricular rate of 80 bpm and normal electrical axis.

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  Figure 2. Initial echocardiographic assessment of the degenerated mitral bioprosthesis. (A) PW Doppler trace across the stenotic mitral bioprosthesis showing pressure half‐time of 486 ms and estimated mitral valve area by PHT of 0.45 cm2. (B) PW Doppler assessment showing elevated transmitral velocities and gradients across the degenerated bioprosthesis, with peak velocity 2.40 m/s, peak transmitral gradient 23.11 mmHg, mean transmitral gradient 13.27 mmHg, and mitral VTI 123.67 cm. (C) Three‐dimensional transesophageal echocardiography demonstrating severely degenerated and calcified bioprosthetic mitral leaflets with markedly restricted mobility. (D) Color Doppler transesophageal echocardiography showing flow acceleration and inflow convergence across the stenotic mitral bioprosthesis, consistent with severe prosthetic mitral stenosis.

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  Figure 3. Preprocedural cardiac CT planning. (A) Inner diameters of the degenerated surgical mitral bioprosthesis measured 25.5 and 24.9 mm, with annular area 6.1 cm2. (B) Virtual positioning of a 26‐mm transcatheter valve at the base of the surgical bioprosthesis. (C) Systolic neo‐LVOT simulation after virtual implantation of a 26‐mm valve, showing predicted neo‐LVOT area 287.6 mm2. (D) CT‐based assessment of aorto‐mitral geometry, showing aorto‐mitral angle 71.3°, inverse angle 108.7°, annular area 6.1 cm2, and A–V distances 70.7 and 55.3 mm.

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  Figure 4. Procedural fluoroscopy. (A) Balloon dilation of the stenotic mitral bioprosthesis after hemodynamic deterioration due to septal dilation. (B) Implantation of 26 mm Edwards SAPIEN 3 valve in the mitral position with slow inflation to allow fine positional adjustment. (C) Final valve position with approximately 80% of the valve in the left ventricle and 20% in the left atrium.

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  Figure 5. Predischarge echocardiography with pulse‐wave Doppler signal through bioprosthetic valve, showing normal function of the implanted prosthesis with mean transmitral gradient 3.5 mmHg at heart rate 111 bpm.