Transseptal implantation of a transcatheter heart valve in a mitral annuloplasty ring to treat mitral repair failure.

A 56-year-old woman was admitted for recurrent, refractory congestive heart failure. When she was aged 17 years, she had a Hodgkin lymphoma treated by chest radiation. She then developed postradiation heart disease, which required surgery in 2004, combining mitral valve repair using a Physio semirigid ring sized 28 mm (Edwards Lifesciences Inc; Irvine, CA) and tricuspid annuloplasty. In March 2009, the patient experienced recurrent congestive heart failure due to mitral valve stenosis. Percutaneous mitral commissurotomy achieved transient symptom relief, but her clinical status severely worsened in the past year. On admission, the patient was in New York Heart Association class IV heart failure. Physical examination showed worrying skin sequelae of chest radiation and severe congestive heart failure. Echocardiography demonstrated severe mitral valve stenosis (mean gradient, 11 mm Hg), regurgitation (grade 3 ), dilatation of the right atrium and ventricle, moderate tricuspid regurgitation, and estimated systolic pulmonary artery pressure 60 mm Hg (Move 1). On multislice CT, the anteroposterior diameter of the mitral ring was calculated at 16 mm and the intercommissural diameter at 27 mm. Because repeated surgery carried a prohibitive risk, a transcatheter option was considered. Because of the cutaneous lesions and postradiation cardiomyopathy, the transapical approach was deemed inadequate; thus, it was decided to intervene through the right femoral vein and a transseptal route. After transseptal catheterization and septal dilation with a 10-mm balloon, crossing the mitral valve with a balloon wedge pressure catheter, a J preshaped 0.035 ExtraStiff wire was placed at the apex of the left ventricle. A 26-mm Edwards Sapien XT transcatheter heart valve was mounted on a Novaflex catheter (Edwards Lifesciences) and advanced to the mitral ring. The prosthesis was then deployed under rapid pacing (Figure 1, Video 2). Postoperatively, the patient’s functional condition rapidly improved. Echocardiographic examination showed a trivial periprosthetic leak and a mean transmitral gradient of 8 mm Hg, a 13-mm Hg gradient was observed in the left ventricular outflow tract, and systolic pulmonary artery pressure dropped to 45 mm Hg