Transcatheter Mitral Valve-in-Valve Replacement Complicated by Valve Embolization

This case illustrates a percutaneous rescue of an embolized valve to the left ventricle during a transcatheter mitral valve-in-valve procedure. Steps included: 1) maintaining wire position across the embolized valve; 2) creating a dual-wire rail by snaring guidewires through the embolized valve; 3) coordinated dual-rail tension applied to withdraw valve toward mitral annulus; 4) second valve deployment; and 5) retrieval of wires entrapped between the 2 valves using a 0.035-inch microcatheter. Pitfalls include loss of wire position across the embolized valve, difficulty snaring wires through the embolized valve, asymmetric tension causing poor coaxial alignment, incomplete annular reapproximation, second valve embolization, paravalvular leak, and difficulty retrieving wires between the valves. A dual-rail system-created by snaring guidewires through the embolized valve-can provide sufficient tension to reapproximate the valve toward the mitral annulus for subsequent percutaneous rescue. Deployment of a second valve within the embolized valve is a viable rescue strategy when surgical intervention is prohibitive.