78 Year frail female with background of DM2, hypothyroidism, Right hemiparesis 10 years back, CRHD - severe MS - post closed mitral valvotomy twice, s/p mitral valve replacement (27 mm magna perimount tissue valve) 14 years back. Currently presented with worsening dyspnea, palpitations, recent admission with pulmonary edema. Pulse 102/MIN, BP 140/70 MMHG, JVP mild elevation, first heart sound normal, loud P2, MDM at apex, PSM grade 3/6 at apex, bilateral fine basal crepts. 

§  Hemoglobin was 11.4  GM/DL, serum creatinine 1.3 MG/DL. NT pro BNP was 567. ECG showed sinus rhythm & LVH. Echo showed Degenerative mitral bioprosthetic valve with severe restenosis, low moderate MR, PPG/MPG : 22/10 MMHG, dilated LA/LV/RA, global hypokinesia of LV, preserved LV systolic function, RV dysfunction, TAPSE – 14 MM, with severe PAH ( RVSP : 66 MMHG ). STS risk mortality score for re do MVR is 6. CT TMVR showed 26 mm valve suitable with neo LVOT of 144.3 MM2.

Pre operative details of bio prosthetic valve and TMVR valve sizing is done through VIV app, which showed 26 MM Sapiens valve to be appropriate with need for LAMPOON in view of narrow neo LVOT and post dilation in case of para valvular leak or patient prosthesis mismatch. 

Under TEE guidance, right femoral vein as primary access, left femoral vein for TPI, left femoral access for pigtail were taken. Septal puncture was done Postero Inferiorly using SL1 8.5 sheath, with BRK needle. Later LA wire placed. SL 1 sheath exchanged with Edward sheath. Over safari 0.035, Agilis 8.5 F stearable sheath placed into LA. Exchange length terumo wire passed across the AV into ascending aorta. Pig tail catheter is exchanged with MPA catheter. A 300 CM Astato wire is taken and bent in the middle and denuded to make a flying V. Then it is passed into ascending aorta. The Astato wire is snared with Goose neck snare (20), through JR, via the left femoral artery to form an AV Loop. Once AV loop is formed Astato wire is insulated by parking microcatheter through arterial side and MPA through venous side. Once the position of the flying 'V' is confirmed in the middle of prosthetic valve leaflet, under continuous dextrose infusion the leaflet is cut with electro cautery pencil. After Lampoon, Astato wire along with AV loop is removed. Then Safari wire is place in LV with help of pigtail. Septal dilatation was done with 12x40mm Mustang balloon. The Edwards Commander delivery system, pre-loaded with Edwards Sapiens 26mm Valve.valve was positioned and deployed. Post deployment there was mild PVL noted in TEE hence the valve was dilated with 26mm Atlas Gold Balloon. After post dilatation there was no PVL. There was no neo LVOT gradient. Post OP hemodynamics were stable.