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.