JSS

We report a case of 71 year old female with history of chronic rheumatic heart disease with severe mitral stenosis who underwent a mitral valve replacement with a Edward Perimount 25mm pericardial tissue valve 12 yrs back. She was apparently normal untill 6 months back when she presented with progressive dysnpnea and intermittent palpitations. She had recurrent admissions with heart failure since 3 months on medical therapy. she was a high risk candidate for a surgery in view of age and redo.

Echocardiogram showed Atrial flutter with variable block.
Echocardiography showed a severely degenerated mitral prosthetic valve with mild MR and no LAA clot.
tee shoba.mp4

Left atrial pressures pre procedure 34mmhg
left atrial pressures post procedure 15mmhg
Coronary angiogram showed Mild disease with slow flow.

patient was sedated under general anesthesia and right femoral and femoral vien access was obtained. 0.32 wire was passed from IVC and septal puncture done with a Brockenborough BRK 1 needle under TEE and fluoro guidence. LA wire was introduced into Left atrium. Septal dilatation was done with a 12x40mm ballon. Then an AGILIS sheath with pigtail was used to cross the previous prosthetic valve and valve was positioned 20/80 placement in LA/LV respectively. Valve was inflated slowly until atrial side dog boning was seen and then inflated quickly. TEE was used to look for Para valvular leak. TEE showed mild PVL. So it was decided for a post dilatation of the valve. After post dilatation PVL disappeared. LA pressure LVEDP were measured. Post procedure TEE showed good gradients of the valve with no PVL. Patient was extubated on table and shifted to ICU with stable hemodynamics.

In conclusion we believe Trans catheter mitral valve in valve procedure is promising in severe bioprosthetic valve degeneration in high risk patients who are not good candidates for surgical valve replacement if properly planned and done in a step wise manner with trans oesophageal echo assistance.