Simultaneous Aortic and Mitral Valve‐in‐Valve Replacement Using Balloon‐Expandable MyVal Valves With Bioprosthetic Valve Fracture

Valve-in-valve transcatheter aortic valve replacement and mitral valve replacement have proved to be a viable alternative to redo surgery in patients who have bioprosthetic valve dysfunction. There is a large subgroup of patients who undergo double valve replacement with bioprosthetic valves, especially in patients with rheumatic heart disease. Failure of these bioprosthetic valves would require a transcatheter management strategy. Transcatheter double valve replacement (TDVR) in these complex cases would require careful evaluation and planning of valve sizing, aortomitral interactions, access, and residual gradients. A 73-year-old man with rheumatic heart disease and prior double bioprosthetic valve replacement in 2014 presented with New York Heart Association class (NYHA) III dyspnea and exertional pre-syncope. He had severe stenosis of a 19 mm Perimount Magna aortic bioprosthesis and a 27 mm Perimount Magna mitral bioprosthesis, with pulmonary hypertension. Computed tomography demonstrated suitable anatomy for transcatheter valve-in-valve treatment. He underwent successful TDVR with a 20 mm MyVal balloon-expandable in the aortic position, followed by a post-implantation valve fracture, and a 27.5 mm MyVal transseptally in the mitral position. The final mean gradients were 15 mmHg across the aortic valve and 6 mmHg across the mitral valve at discharge. At 1-year follow-up, the patient remained clinically well without an increase in valve gradients. Simultaneous transcatheter aortic and mitral valve-in-valve replacement can be performed successfully in selected high-risk patients after meticulous multimodality planning. In patients with a small surgical aortic bioprosthesis, intentional bioprosthetic valve fracture may be an important adjunct to optimize post-implantation hemodynamics. This report highlights the complexity of procedural planning for bioprosthetic valve fracture in a small aortic valve, ensuring optimal hemodynamics and the safety and durability of the Myval transcatheter heart valve in challenging and complex procedures like TDVR.