First ever transmitral valve in valve replacement in India.

Dear Editor,

Transcatheter valve implantation (TAVR or TAVI) is now a well-established modality of therapy for inoperable & surgically higher intermediate risk patients of native severe symptomatic aortic stenosis. Redo-surgery is still considered gold standard for degenerated malfunctioning bioprosthetic valves at aortic, mitral or tricuspid position, however repeat sternotomy in elderly patient with multiple comorbidities leads to high morbidity and mortality. A off-label percutaneous trans-femoral valve in valve procedure offer an alternative option for these high surgical risk patients.

We present a unique case of a successful percutaneous trans-septal mitral valve in valve implantation using the Edwards SapienS3 valve (26 mm) in a high-risk patient deemed to be inoperable for conventional redo- valve surgery (Refs. 1, 2, 3, 4).

This is an 82 year old lady who underwent mitral valve replacement surgery in 2006 using a bioprosthetic valve (Perimount 25 mm) for rheumatic severe mitral stenosis and severe mitral regurgitation. She underwent an ICD implantation in 2013 for sustained monomorphic ventricular tachycardia with hemodynamic compromise and a pulse generator replacement in 2017. She presented with NYHA Class III–IV dyspnea with palpitations and an echocardiogram revealed degenerated severely stenotic bioprosthetic valve, mild regurgitation with a mean gradient of 12 mmHg, with mild tricuspid regurgitation with peak velocity of 4 m2 with dilated non collapsing IVC and normal LV function. She underwent evaluation for a redo Mitral valve replacement. Her Society for Thoracic Surgery (STS) score predicted an in-hospital mortality of 51.5% with surgery and EURO score 2 of 51.97% intraoperative mortality. A heart team consultation recommended transcutaneous valve in valve procedure considering extreme risk of redo MVR.

She was evaluated with computerized tomographic imaging of aortic valve aortic root and entire aorta for vascular access, and CT sizing and procedure planning. Her coronary arteries were unremarkable. Patient was planned for trans-femoral trans-septal valve in valve procedure after taking informed consent from patient and family.

Patient underwent transcutaneous valve in valve procedure under general anesthesia with trans esophageal echocardiographic (TEE) and fluoroscopic guidance using a Edward Sapien- S3, (26 mm) valve. Right femoral venous access was used for procedure with TEE guided septal puncture and Agilis deflectable Sheath was positioned in left atrium after dilating the septum with a 10 mm balloon for easy manipulation. Hemodynamic assessment showed a 12 mmHg of transmitral gradient. Mitral valve was crossed with a pigtail catheter and a Confida support wire was positioned in left ventricle. Edward sapien S3 (26 mm) valve was mounted on a 26 mm true balloon in reverse position and positioned across rim of previous bioprosthetic valve and inflated with trans venous pacing at 180 bpm for accurate positioning. Post implant hemodynamics showed a no diastolic gradient across mitral wall. TEE showed a mean gradient of 5 mmHg across mitral valve with Iatrogenic atrial septal defect was closed using a Amplatzer device. She was extubated on table and shifted to ICU for monitoring for next 48 h. Post procedure day 5 patient was discharged in a stable condition with NYHA class I status (Fig. 1, Fig. 2, Fig. 3).

Fig. 1

Mitral PHV Pre and post Intervention.

Fig. 2

Trans-mitral gradient Pre and Post procedure.

Fig. 3

Edward Sapien S3 valve positioned at aortic position (A), Implanted (B), ASD device closure (C).

Conflict of interest

This is to certify that We Dr. Rashmi Xavier, Dr. Praveen Chandra, Dr. Nagendra S Chouhan & Dr. Naresh Trehan do not have any conflict of interest.