Transseptal Mitral Valve-in-Valve-in-Valve

Figures

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  Figure 1. Two-dimensional TEE, midesophageal long-axis (140°) view, systolic phase (A), demonstrates a well-seated mitral ViV (green arrow) following the initial procedure and (B) long-axis (157°) view, systolic phase, demonstrates migration of the ViV prosthesis (white arrow) 11 mm into the left atrium (LA) 1 year later.

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  Figure 2. Two-dimensional TEE, midesophageal view with color flow Doppler–guided continuous-wave spectral Doppler display, demonstrates (A) high MV mean pressure gradient (7 mm Hg, heart rate 33 beats/min) before mitral ViViV insertion and (B) reduced MV mean pressure gradient (4 mm Hg, heart rate 45 beats/min) immediately following mitral ViViV implantation.

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  Figure 3. Three-dimensional TEE, volume-rendered reconstruction display, en face view from the perspective of the LA, demonstrates (A) the initial 27-mm bioprosthetic MV (yellow arrow) and 23-mm ViV (red arrow), which has migrated toward the LA, and (B) the new 26-mm transcatheter valve implanted during the mitral ViViV procedure (white arrow) sitting within the initial ViV prosthesis.

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  Figure 4. Fluoroscopic images (A) immediately following previous ViV procedure, demonstrates 23-mm transcatheter valve edge (red outline) in line with islets of previous 27-mm bioprosthetic MV (green line). (B) After 1 year, migration of 23-mm transcatheter valve (red outline) from the islets of the bioprosthetic MV (green line). (C) Transcatheter 26-mm ViViV (white outline) well seated in comparison with bioprosthetic valve islets, preventing further migration of previously placed 23-mm ViV.

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  Figure 5. (A) Two-dimensional TEE, midesophageal long-axis (155°) view, systolic phase, demonstrates moderate PVR (red arrow) between 27-mm bioprosthetic MV and 23-mm ViV, with migration toward the LA. (B) Two-dimensional TEE, midesophageal long-axis (140°) view, demonstrates the absence of PVR (green arrow) following implantation of the new 26-mm transcatheter valve in previous ViV apparatus.

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  Figure 6. (A) Three-dimensional TEE, volume-rendered reconstruction with color flow Doppler display, en face view of the MV from the perspective of the LA, systolic phase, demonstrates paravalvular and supraskirtal regurgitation (white arrow) from the 9 o’clock to 1 o’clock positions arising between 27-mm bioprosthetic MV (yellow arrows) and 23-mm ViV (red arrows) and (B) resolution of the PVR following implantation of the new 26-mm ViViV.