Abstract 4366346: Mitral Valve-in-Valve in Rheumatic Heart Disease: Challenges in the Presence of Severe Calcification of the Surgical Bioprosthesis

Introduction: Patients with rheumatic heart disease (RHD) who undergo surgical early mitral valve replacement (MVR) may later require reintervention. Transcatheter mitral valve-in-valve (ViV) implantation is a challenging but increasingly viable option, especially in high-risk patients. We report a complex mitral ViV procedure in a 78-year-old woman with multiple comorbidities and severe mitral bioprosthetic valve failure. Case Report: A 78-year-old woman with a history of RHD and surgical MVR 12 years prior was readmitted for progressive dyspnea (NYHA III) and pulmonary edema despite high-dose diuretics. Past history included hypertension, atrial fibrillation, chronic kidney disease (Cr=3.0 mg/dL), and VVi pacemaker. Catheterization revealed severe pulmonary venocapillary hypertension (27 mmHg), moderate pulmonary artery hypertension (59×22 [35] mmHg), and elevated right atrial pressure (19 mmHg). Transesophageal echo showed severe regurgitation of a severely calcified mitral bioprosthesis (external effective annulus=26 mm). Left ventricle (LV) outflow tract obstruction risk was low (area: 292 mm 2 ). STS-PROM mortality for surgical reintervention was 8.2%. The heart team opted for mitral ViV with a Sapien Ultra 29mm valve. Using a Swartz 8F sheath and BRK needle, a posteroinferior transseptal puncture was performed, and a 0.035" guidewire was advanced to the LV and exchanged for a pigtail catheter. A Safari extra-support guide was then positioned in the LV, and a second stiff wire was placed in the superior left pulmonary vein. Due to difficulty advancing the prosthesis, sequential septal dilations were performed with 8.0 mm and 10.0 mm balloons. The Sapien Ultra was then advanced across the septum but could not cross the stenotic surgical valve. The wire was repositioned from the pulmonary vein to the LV, and valvuloplasty was done with a 20×30 mm AltoSa balloon. The valve was then successfully navigated and implanted under rapid pacing with nominal deployment. Post-procedure 3D echo confirmed good valve dynamics with a mean gradient of 2 mmHg and visualization of a ruptured surgical leaflet. At 4-month follow-up, the patient remains in NYHA class I, with no adverse events. Conclusion: This case illustrates the feasibility of mitral ViV in RHD with severe prosthetic calcification. Preprocedural planning, balloon preparation, and wire strategy were critical for success. The Sapien Ultra prosthesis provided excellent hemodynamic results in a high-risk patient.