Pulmonary Hypertension Hyper-Responder to Valve-in-Valve TMVR Under Conscious Sedation

Severe pulmonary hypertension (PH) is a relative contraindication to left-sided valve replacement given elevated risk of decompensation.

A 64-year-old woman with prior atrioventricular canal repair, bioprosthetic mitral valve replacement, and suprasystemic group II PH presented with recurrent heart failure admissions in the setting of severe bioprosthetic valve regurgitation. Considered at prohibitive risk for redo surgery, she underwent valve-in-valve transcatheter mitral valve replacement (TMVR) under intracardiac echocardiography (ICE) guidance and conscious sedation. Pulmonary artery systolic pressure decreased from the 110s to the 80s mm Hg postprocedure and to the 50s mm Hg with sildenafil optimization. At 9 months postprocedure, she had improved to NYHA functional class I-II status.

This case illustrates the safety and feasibility of ICE-guided TMVR without general anesthesia in patients with severe PH. It highlights a "hyper-responder" physiology after correction of left-sided valve pathology and optimization of pulmonary vasodilators.

ICE-guided TMVR under conscious sedation (in combination with pulmonary vasodilators) can be safe in select severe PH patients, achieving significantly lower pulmonary pressures with meaningful symptom improvement.