Transseptal Mitral Valve-in-Valve Implantation Using an Arteriovenous Loop

BACKGROUND: Transseptal mitral valve-in-valve (ViV) implantation is an established therapy for failed surgical bioprostheses. However, massive biatrial enlargement can preclude delivery, leading to procedural failure. CASE SUMMARY: A 75-year-old woman presented with heart failure after surgical mitral bioprosthesis implantation. Echocardiography revealed severe mitral bioprosthetic failure and massive biatrial enlargement. Computed tomography angiography showed a septal-annular angle of 106°. During the procedure, the stiff wire and the delivery system repeatedly prolapsed into the giant atrium. A full-body rail was created by snaring the guidewire from the femoral artery, providing adequate support. Then a 23 mm SAPIEN 3 valve was successfully deployed. Post-procedural mean gradient decreased to 4 mmHg with mild paravalvular leak. The patient recovered uneventfully with significant functional improvement. DISCUSSION: The full-body rail technique is a critical bailout strategy for mitral ViV in patients with massive atria, enabling coaxial alignment and safe delivery. TAKE HOME MESSAGES: • Massive biatrial enlargement and a horizontal septal-annular angle (>100°) can preclude standard delivery during mitral ViV. • The step-by-step creation of a full-body (arteriovenous) rail is a rescue technique to stabilize the delivery system.