Transesophageal echocardiography guidance of percutaneous mitral valve replacement in failed annuloplasty ring: A case report.

Severe mitral regurgitation and stenosis due to failed mitral annuloplasty ring can be managed with percutaneous mitral valve in ring in high surgical risk patients. A 66-year-old male underwent coronary artery bypass surgery and mitral valve ring annuloplasty 7 years previously. He started to have shortness of breath with minimal effort in the past 2 years. Transthoracic echocardiogram revealed a new severe mitral regurgitation and severe mitral stenosis. The patient was turned down from surgery due to high surgical risk. The transcatheter mitral valve in ring implantation was decided. In this case, there was a low probability of left ventricular outflow tract obstruction. A stiff wire crossed the mitral valve ring and positioned in the left ventricular apex. The Sapien 3 valve size 26 mm (Edwards Lifesciences, Irvine, CA, USA) was positioned to have 80% ventricular and 20% atrial side. Transesophageal echocardiogram evaluation revealed a mean gradient of 5 mmHg. The left ventricular outflow tract (LVOT) had laminar color flow and the mean pressure gradient across LVOT was 1 mmHg. The patient was discharged after 2 days in good condition. At one year follow up, he had no shortness of breath and no rehospitalization. In conclusion, the percutaneous mitral valve in ring is feasible in selected patients. The risk of LVOT obstruction should be assessed carefully before the procedure with a transthoracic and transesophageal echocardiogram. 〈 Understand how to guide the mitral valve in ring procedure with a transesophageal echocardiogram and how to avoid left ventricular outflow tract obstruction. Understand how to position the Sapien valve in mitral valve ring.〉.