Transseptal Mitral Valve-in-Valve Implantation Using an Arteriovenous Loop
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Published on: October 16, 2021
Yan-Jie Li1, Lan Ma2, Zi-Yong Hao1
1Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
Background:
Transseptal mitral valve-in-valve (ViV) implantation is an established therapy for failed surgical bioprostheses. However, massive biatrial enlargement can preclude delivery, leading to procedural failure.
Case Summary:
A 75-year-old woman presented with heart failure after surgical mitral bioprosthesis implantation. Echocardiography revealed severe mitral bioprosthetic failure and massive biatrial enlargement. Computed tomography angiography showed a septal-annular angle of 106°. During the procedure, the stiff wire and the delivery system repeatedly prolapsed into the giant atrium. A full-body rail was created by snaring the guidewire from the femoral artery, providing adequate support. Then a 23-mm SAPIEN 3 valve was successfully deployed. Postprocedural mean gradient decreased to 4 mm Hg with mild paravalvular leak. The patient recovered uneventfully with significant functional improvement.
Discussion:
The full-body rail technique is a critical bailout strategy for mitral ViV in patients with massive atria, enabling coaxial alignment and safe delivery.
Take-Home Messages:
Massive biatrial enlargement and a horizontal septal-annular angle (>100°) can preclude standard delivery during mitral ViV implantation. The step-by-step creation of a full-body (arteriovenous) rail is a rescue technique to stabilize the delivery system.
