Transfemoral Transseptal Mitral Valve-in-Valve-in-Valve of a Degenerated Transcatheter in Surgical Bioprosthesis.

Objective: The authors describe a transcatheter mitral valve-in-valve-in-valve (VIVIV) for the correction of a degenerated transcatheter in a surgical bioprosthesis, a challenging interventional scenario that will be increasingly frequent in the near future.

Key Steps: The key steps taken were as follows: preprocedural planning integrating data from transesophageal echocardiogram, cardiac computed tomography, and 3mensio reconstruction (Pie Medical Imaging); transfemoral transseptal VIVIV performed with EchoNavigator system (Philips) guidance; Sapien Ultra 3 26-mm valve (Edwards Lifesciences) delivered with buddy balloon maneuvers to uncage the valve from the atrial struts of the previously implanted valve; and atrial septal defect occlusion with the Amplatzer ASO 24 mm (Abbott Cardiovascular).

Potential Pitfalls: The inability to advance the prosthesis into the ventricle, irreversible hemodynamic collapse, residual high transmitral mean gradient because of impingment of the 3 valves, residual paravalvular leaks, and left ventricular outflow tract obstruction.

Take-home Messages: Mitral VIVIV procedures represent a viable option for patients with prohibitive surgical risk and a degenerated transcatheter in surgical bioprostheses. Success hinges on adequate preprocedural planning and a thorough understanding of bailout techniques to minimize failure and prevent major complications.