Abstract 16053: Mitral Valveception: The Promising Technique of Mitral Valve-in-Valve Replacement for Bioprosthetic Valve Dysfunction

Introduction: Degeneration of bioprosthetic mitral valves often presents as regurgitation or stenosis. The gold standard is surgical repair; however, many patients are considered too high risk for repair and therefore transcatheter mitral valve replacement (TMVR) can be considered in appropriately selected patients. We present a Mitral Valve in Valve (ViV) replacement as a rescue option for severe bioprosthetic mitral stenosis.

Case: A 45-year-old male with a history of IV drug use, ischemic cardiomyopathy with placement of ICD and severe mitral regurgitation s/p bioprosthetic MVR (27mm Edwards) 7 years ago presented with dyspnea. He was found to have decompensated heart failure with evidence of cardiogenic shock. He required inotropes and admission to the Cardiac ICU. Echocardiogram demonstrated biventricular dysfunction with an EF of 15%, and a well-seated malfunctioning bioprosthetic valve with fixed posterior leaflets and severe degenerative stenosis (3D planimetry valve area 0.85cm2). His cardiogenic shock was felt to be in the setting of severe mitral stenosis on the background of underlying cardiomyopathy. He was deemed a poor surgical candidate by multidisciplinary team with an STS mortality and morbidity risk of 39% and 85%. He hence underwent a mitral ViV with successful placement of a 29mm Edwards SAPIEN 3 transcatheter valve with impella protection. Patient improved and was discharged off inotropes.

Discussion: Surgical mitral valve replacement remains the standard of care currently for degenerated bioprosthetic mitral valves. Patients at heightened risk may require ViV procedure instead. In ViV, the ring of the bioprosthetic valve can serve as an anchoring point for the new valve. This avoids a major limitation with TMVR in the native mitral annulus. Severity of acute illness proved to be the determining factor heightening the need for ViV replacement as a rescue option in our patient.

Conclusion: Management of failing surgical mitral bioprosthesis remains a challenge. ViV-TMVR is an evolving approach that can be used as an alternative in patients who are not surgical candidates. Low rates of periprocedural morbidity and mortality reported in literature strengthen the argument for TMVR, although more data is needed to guide management.