Severe Bioprosthetic Mitral Valve Dysfunction: Multimodality Imaging Identifies Structural Valve Degeneration and Guides Valve-in-Valve TMVR.

BACKGROUND: Severe bioprosthetic valve dysfunction presents a diagnostic challenge because distinguishing reversible leaflet thrombosis from structural valve degeneration may not be possible using echocardiography alone. CASE SUMMARY: A patient with end-stage renal disease, previous bioprosthetic mitral and aortic valve replacement, and prior valve-in-valve transcatheter aortic valve replacement presented with heart failure and cardiogenic shock. Multimodality imaging demonstrated severe bioprosthetic mitral valve dysfunction with restricted leaflet motion, raising suspicion for leaflet thrombosis. Empiric intravenous unfractionated heparin was commenced while cardiac computed tomography was arranged. Computed tomography excluded hypoattenuated leaflet thickening and demonstrated severe leaflet calcification, confirming structural valve degeneration. After heart team discussion, transseptal valve-in-valve mitral replacement resulted in rapid hemodynamic and clinical recovery. DISCUSSION: Serial multimodality imaging guided escalation from anticoagulation to definitive valve intervention. TAKE-HOME MESSAGES: Persistent prosthetic valve dysfunction after anticoagulation should prompt reassessment for structural valve degeneration. Transseptal valve-in-valve transcatheter mitral valve replacement is an effective treatment for selected high-surgical-risk patients.