A 68-year-old man was referred in 2023 for transcatheter management of severe mitral regurgitation, due to a prior episode of infective endocarditis at an unknown point in time. In 2015, he underwent mitral valve replacement with biologic prosthesis Labcor 33 (Labcor Laboratórios Ltda, Contagem, Brazil) and tricuspid annuloplasty with Edwards MC3, 34 mm ring (Edwards Lifesciences, Irvine, California, United States).

Eight years after the surgery, transesophageal echocardiography (TEE) revealed a perforated mitral prosthetic leaflet causing severe regurgitation (Figure 1A and 1B). Our patient was deemed ineligible for cardiac surgery due to multiple comorbidities.

Figure 1. Images of mitral valve-in-valve rescue procedure in different modalities; A – perforated mitral prothesis leaflet (arrow) on transesophageal echocardiography (TEE); B – severe mitral regurgitation on TEE with color Doppler; C – challenges in delivery system navigation due to enlarged left atrium on angiography; D – nonuniform balloon inflation during transcatheter heart valve (THV) deployment; E – anchoring the proximal part of the previous loose THV to another THV using a delivery system, stiff wire, and a pigtail catheter (arrow); F – the final result on angiography; G – complete expansion of the prostheses on TEE; H – no left ventricular outflow tract obstruction on computed tomography

Valve-in-valve transcatheter mitral valve implantation (ViV-TMVI) was performed, utilizing fluoroscopic and TEE guidance. We pursued a widely accepted procedure to deliver balloon-expandable Sapien 3, 29 mm valve (Edwards Lifesciences) via the right femoral vein by the transseptal approach and during rapid pacing. However, we found it extremely difficult to navigate within the enlarged left atrium despite what seemed to be an optimal posteroinferior interatrial septum puncture (Figure 1C). We finally reached a desired position of transcatheter heart valve (THV) after several unusual and harsh bendings of the delivery system. Excessive maneuvers and bending could possibly contribute to delayed and nonuniform balloon inflation, which in turn resulted in bioprosthesis dislodgement into the left ventricle (Figure 1D). As the surgery was a risky option, we decided to use another valve. During extended rapid pacing with cautious interplay of the delivery system and stiff wire (distal loopy part acting as a snare enabling us to draw the THV closer to the subvalvular position), we were able to deploy another Sapien 3, 29 mm valve anchoring the proximal part of the previous loose valve (Figure 1E–1G).

Postoperative echocardiography confirmed complete expansion of the prostheses with a mean gradient of 4 mm Hg and effective orifice area of 1.8 cm2, which are in line with previously reported data.1,2 No paravalvular leak was noted. Despite double frames of bioprostheses, no left ventricular outflow tract obstruction was observed either on echocardiography (peak gradient of 10 mm Hg) or on computed tomography (Figure 1H). The postprocedural period was uneventful.

Our case report demonstrates transcatheter bailout management of a dislodged prosthesis during mitral valve-in-valve implantation. In Poland, data on ViV-TMVI remain limited.3 As the number of patients with failed mitral bioprostheses, who are ineligible for redo surgery, continues to rise, further studies on the safety, efficacy, and long-term outcomes of ViV-TMVI are warranted.