Trans-catheter mitral valve-in-valve replacement in a patient on venoarterial extracorporeal membrane oxygenation: a case report.

Background: Bioprosthetic mitral valves on average have a median durability between 8 and 10 years. After the failure of a bioprosthetic valve, surgical replacement is often indicated. However, the options for those patients at high or prohibitive surgical risks are limited. Here, we describe a case of a successful trans-catheter mitral valve-in-valve (TMViV) replacement on venoarterial extracorporeal membrane oxygenation (VA-ECMO). Case summary: We describe a case of a 39-year-old female with a history notable for systemic lupus erythematosus, severe pulmonary arterial hypertension (now mixed pre and post) thought to be secondary to prior substance use, and infective endocarditis complicated by severe mitral stenosis status post-bioprosthetic mitral valve replacement who presented with symptoms of acute hypoxic respiratory failure secondary to severe bioprosthetic mitral valve stenosis. The patient had a prolonged hospital course complicated by a pulseless electrical activity arrest, (continuous renal replacement therapy) for acute renal failure, and hypertonic saline due to cerebral oedema. Due to her significant co-morbidities and haemodynamic instability with acute kidney injury and recent neurologic insult, the patient was thought not to be a good surgical candidate. However, given her young age and overall improved neurologic status, it was thought the patient could benefit from a TMViV with bi-ventricular support given her right- and left-sided heart failure and was placed on VA-ECMO in anticipation of a TMViV procedure for circulatory support. The patient underwent a successful TMViV replacement using a trans-septal approach with a 26 mm SAPIEN 3 valve and atrial septal defect closure with a 14 mm Amplatzer device on hospital Day 12. The patient was successfully de-cannulated from VA-ECMO on hospital Day 13. The patient had a prolonged hospital course but eventually had renal recovery and tracheostomy de-cannulation. A trans-thoracic echocardiogram prior to discharge was notable for a well-functioning valve and normal ejection fraction. The patient was discharged to a nursing home for further rehabilitation. Discussion: The gold standard for bioprosthetic mitral valve stenosis is surgical replacement of the valve. However, the options for those at high or prohibitive surgical risk are lacking. Recent studies have demonstrated TMViV is a safe alternative to surgical mitral valve redo cases in high-risk patients. To our knowledge, there are limited data on trans-catheter valve placement while on VA-ECMO. Successful implantation in our patient suggests that TMViV in a stenotic bioprosthesis is feasible in very high-risk patients with the use of VA-ECMO to support haemodynamics.