Asia's first successful minimally invasive transapical transcatheter mitral valve-in-valve implantation.

Case Report A 72-year-old man with hypertension, hyperlipidaemia, diabetes and renal impairment presented with recurrent heart failure from a severely leaking mitral bioprosthesis. He had undergone 2 previous coronary bypass operations, 25 years and 7 years ago respectively. His porcine mitral valve implanted during his most recent bypass surgery was severely regurgitant from a fl ail leafl et (Figs. 1A and 1B). The peak and mean transmitral gradients were 16 mmHg and 5 mmHg respectively, with an effective orifi ce area of 1.71 cm2. There was moderate tricuspid regurgitation and elevated systolic pulmonary artery pressures (79 mmHg). His left ventricular ejection fraction was 55% to 60%. His mammary artery graft to the anterior descending coronary artery and vein graft to the obtuse marginal were patent, whilst the vein graft to the ramus intermedius was diseased (Fig. 1C). The graft to the diffusely diseased right posterior descending artery was occluded but deemed not clinically signifi cant.