Procedure and Results
The transcatheter MV implantation procedure was conducted in a standard manner under general anesthesia in all patients using the transapical approach.11 Under both 2DTTE and 3DTEE vision, a guidewire was inserted into the left ventricle through a small incision in the fifth or sixth intercostal space in the apical area guided by 2DTTE. Using both 2D and 3DTEE guidance in addition to fluoroscopy, the guidewire was advanced into the malfunctioning bioprosthesis/ring. Thereafter, it was very carefully and slowly advanced into the LA body and left upper pulmonary vein making sure there was no contact with the thrombus whose location and size were well displayed by both 2D and 3DTEE. Biplane imaging by 2DTEE and careful and systematic cropping of 3DTEE datasets were most helpful in delineating under direct vision the relationship between the thrombus and guide wires used as well as the larger prosthesis delivery system. Thus, thrombus fragmentation and/or dislodgement were avoided. All transcatheter implantations were successfully performed as previously described using a balloon-expandable transcatheter heart valve (Edward Sapien 3, XT, Edwards Lifesciences, Irvine, CA, USA or Lotus, Boston Scientific, Marlborough, Maryland, USA).12 The average duration of the procedure was 122.8 minutes, with a range of 54 to 210 minutes. The patient with associated severe prosthetic aortic valve stenosis also underwent successful redo transcatheter aortic valve in valve implantation during the same procedure. In all patients, the newly implanted prosthetic MV in valve showed unrestricted motion with no paravalvular and none or only trivial valvular regurgitation. The mean mitral prosthetic valve gradients following implantation ranged from 2 to 7 mmHg. None of the patients showed any clinical, laboratory or other evidence of embolization during or immediately following the procedure as well as during the follow up period which ranged from 3 to 36 months with a mean of 21 months. Both left and right ventricular function as well as other associated valvular and other findings remained unchanged as compared to before the procedure. All patients also had amelioration of their symptoms.