Figure legends
Figure 1. A: Degenerated calcific bioprosthetic mitral valve, with aorta-mitral valve angle of 63°. B: Mean pressure gradient of mitral valve is 18 mm Hg. C: Estimated systolic pulmonary artery pressure from the tricuspid regurgitation jet is 66 mm Hg. D: Transoesophageal echocardiography 2D shows degenerated bioprosthesis. E: 3D zoom from the left atrium (diastolic frame) shows mitral valve not opening. F: 3D zoom from the left ventricle shows thickened and calcified mitral valve.
Figure 2. A: Transseptal wire passing the degenerated mitral valve. B: Balloon dilation (14-mm) of interatrial septum. C: 3D balloon dilation of the bioprosthetic mitral valve. D: Balloon dilation of degenerated mosaic bioprosthetic mitral valve. E: Snaring of the wire from the left ventricle to the aorta. F: Deployment of the 23-mm Edwards SAPIEN 3 valve.
Figure 3. A: 3D deployment of 23-mm Edwards SAPIEN 3 valve. B: Fluoroscopy of deployed valve. C: Mean pressure gradient of valve-in-valve is 5 mm Hg. D: 2D colour image of deployed valve. E: 3D image of deployed valve in diastole showing valve opening well. F: Vascular plug closing the right ventricle apical puncture.
Figure 4. A: Apical, four-chamber view before mitral valve-in-valve with dilated right ventricle. B: Apical, 4-chamber view at 30-month follow-up showing smaller right ventricle. C: Estimated systolic pulmonary artery pressure at 30-month follow-up is 33 mm Hg. D: Mean pressure gradient at left ventricular outflow tract is 10 mm Hg, indicating no obstruction. E: Mean pressure gradient of mitral valve-in-valve at 30-month follow-up is 6 mm Hg.