Case report.
A 75-year-old woman who had previously undergone mitral valve replacement seven years earlier with an Edwards Magna 31mm valve (Edwards Lifesciences) that was complicated by severe left ventricle ejection fraction (LVEF) decrease (visually estimated at 25%) and hemicolectomy was admitted for progressive dyspnea and reduced functional capacity. She was anticoagulated for paroxysmal atrial fibrillation. Transthoracic echocardiography (TTE) showed a severely reduced LVEF at 30% and severe mitral stenosis (mean gradient: 25 mmHg at 108 beats per minute (Figure panel A and Supplementary file video 1), valve area at 0.7cm2 by direct planimetry using 3-dimensional transesophageal echocardiography (TEE)) with restricted leaflet mobility (Figure panel B). After Heart-Team discussion, a second mitral valve replacement was deemed at too high risk considering the LVEF. We decided to perform a transseptal TMViV using a 29mm Edwards Sapien S3 transcatheter heart valve (THV) mounted on a transfemoral Edwards Commander Delivery System in an antegrade position.
After positioning a Sentinel cerebral protection device (Boston Scientific) in the brachiocephalic trunk and the left carotid artery, we punctured the right femoral vein, performed a transseptal puncture followed by a dilatation of the septum by an inflation of a 12x40 mm Powerflex Pro 0.035 balloon (Cardinal Health TM). Subsequently, a medium Agilis steerable transseptal sheath (Abbott Vasc) was advanced to facilitate the advancement of an extra-small 0.035 Safari guidewire (Boston Scientific) into the LV apex through a 6 French pigtail catheter. After optimal positioning under fluoroscopic and TEE guidance, the balloon-expandable valve was deployed under rapid pacing at 180 bpm (Figure panel C) with significant mean gradient reduction from 25 to 3.6mmHg post-procedure (Figure panel D) and no residual regurgitation. Of note, the baseline gradient was overestimated due to tachycardia. Panel E of the figure (and Supplementary file video 2) shows fully opened leaflets at 3-dimensional echocardiography. After retrieval, the Sentinel device showed multiple micro debris (Figure panel F). At 1 year, the patient was in a functional class New York Heart Association I with transprosthetic mean mitral gradient of 7 mmHg. Despite optimal heart failure treatment, LVEF remained severely reduced (30%) and the patient underwent primary prevention insertion of an implantable cardioverter defibrillator.