Degenerated Bioprosthetic Mitral Valve: Redo Surgery or Percutaneous Replacement?

A 75-year-old woman with a history of failed surgical mitral valve repair presented with severe symptomatic mitral regurgitation (MR) and underwent surgical mitral valve replacement (MVR) with a 25-mm Carpentier-Edwards Perimount Magna (Edwards Lifesciences; Irvine, CA) bovine bioprosthesis.

The patient presented 2 years later with severe progressive dyspnea on exertion. Diuretics afforded her only minimal relief. Cardiac catheterization revealed angiographically normal coronaries, moderate pulmonary hypertension (pulmonary artery pressures 50/27(35) mmHg), and markedly elevated pulmonary artery wedge pressure (33 mmHg). Three-dimensional (3D) transesophageal echocardiography (TEE) demonstrated severe stenosis of the mitral bioprosthesis (mitral valve area of 0.6 cm2 by 3D planimetry) (Video 1) secondary to commissural fusion, as well as mild transvalvular MR. Left ventricular systolic function remained normal.

Video 1

Because the patient was deemed to be at high risk for repeat surgical MVR—with morbidity or mortality estimated to be 38% using the Society of Thoracic Surgeons (STS) calculator—an alternative approach was sought. She underwent percutaneous mitral balloon valvuloplasty (PMBV) (Video 2). PMBV produced a 2.5-fold increase in the mitral valve area to 1.5 cm2 by 3D TEE planimetry and a decrease in mean mitral valve gradient from 16 mmHg to 6 mmHg.

Video 2

The patient experienced a dramatic improvement in her symptoms. However, she returned 2 years later with recurrent profound dyspnea and was found to have severe restenosis of her bioprosthetic mitral valve (mitral valve area of 0.8 cm2).

Which intervention is most appropriate for this patient at this time?

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