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A Case Series of Percutaneous Aortic Valve Implantation in the Native Mitral Position
Negareh Mousavi, Fahd Makhdom, Joe Martucci, Jean Buithieu, Benoit De Varrennes, Kevin Lachapelle, NIcolo Piazza.
McGill University Health Center, Montreal, QC, Canada.

Advances in transcatheter aortic valve replacement have spurred the development of innovative approaches for other high-risk patient subsets. However, due to the complexity of the mitral valve anatomy, development of transcatheter intervention for mitral valve pathologies has been lacking in speed. We report three cases of percutaneous aortic valve placement in mitral position.
Patient Demographics
Cases were 3 females ages 71, 83 and 68 respectively.
Relevant History
All 3 patients had prior history of coronary artery disease and bypass surgery. All presented with symptoms of heart failure due to either severe mitral regurgitation, stenosis or mixed disease.
Pre-Operative Plan
None of the patients were surgical candidates for mitral valve replacement/repair given heavily calcified mitral valve/annulus and concomitant comorbidities. A percutaneous approach was devised.
Discussion
The first case was a 71-year-old patient with severe calcific mitral stenosis who underwent transcatheter mitral valve implantation via a transapical approach. Several attempts at positioning a 27 mm Lotus valve failed as a result of either outflow tract obstruction when valve placed too low, or severe mitral regurgitation when valve placed too high. The Lotus valve was therefore explanted following these unsuccessful attempts.
The second case was an 83-year-old patient with prior history of surgical aortic valve replacement and coronary artery bypass who presented with severe mitral regurgitation. Attempt at placement of a 29 mm Edwards SAPIEN valve under direct vision was unsuccessful with migration of the valve into the left atrium. Emergency valve explantation and mitral valve repair were performed.
The third case was a 68-year old patient with prior history of chronic renal insufficiency and parathyroid disease with severe calcific mitral stenosis and severe MR, who underwent a successful implantation of a 29 mm Edwards SAPIEN valve via sternotomy.
This case series demonstrates the challenges associated with transcatheter replacement of a calcified mitral valve using existing transcatheter aortic valve technologies. Further studies are needed to determine optimal patient and prosthesis selection, and access routes.


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