Abbreviations
JL, Judkins Left
LA, Left atrium
LV, Left ventricle
ViV-TMVR, Transseptal valve-in-valve transcatheter mitral valve replacement
INTRODUCTION
Transseptal valve-in-valve transcatheter mitral valve replacement (ViV-TMVR) is a safe and effective procedure to treat a failed bioprosthetic mitral valve. ViV-TMVR is less invasive and associated with lower short-term mortality and morbidity compared to redo surgical mitral valve replacement.1,2 Currently, ViV-TMVR is commonly performed using a steerable sheath, such as the Agilis (Abbott Laboratories, Lake Bluff, IL, USA), which is advanced into the left atrium (LA) and directed toward the left ventricular (LV) apex following transseptal puncture. This facilitates guidewire crossing, particularly in cases with an unfavorable trajectory toward the LV. Although the use of an Agilis sheath is not mandatory, it not only aids in guidewire passage into the LV but also provides support for the advancement of a Safari wire (Boston Scientific, Marlborough, MA). Given the cost associated with steerable sheaths, we describe a technique for a simplified ViV-TMVR without using the Agilis sheath.
CASE PRESENTATION
Eight ViV-TMVR procedures were performed consecutively using the simplified technique in our institution. After the transseptal puncture, the Braided SL transseptal sheath (Abbott Laboratories, Lake Bluff, IL, USA) was advanced into the LA (Figure 1A). A 5 Fr Judkins Left (JL) 100 cm catheter was introduced via the Braided SL sheath into the LA and manipulated towards the LV. A J-tip wire was inserted into the JL catheter and directed into the LV. The Braided SL sheath was then advanced into the frame of the failed mitral bioprosthesis to increase the support that a Safari wire could be easily passed through the JL catheter or an exchanged pigtail into LV for balloon septostomy and valve deployment (Figures 1B to 1D). The use of cerebral protection devices and valve fracture was at operator discretion.
Figure 1.
Procedures of the simplified transseptal valve-in-valve transcatheter mitral valve replacement. (A) The Braided SL sheath was inserted into the left atrium (LA). (B) The J tip wire was advanced into the left ventricle using the Judkins Left catheter. (C) The Braided SL sheath was advanced into the valve frame. (D) Deployment of the SAPIEN 3 valve.
DISCUSSION
Our initial experience demonstrates that this simplified ViV-TMVR strategy is feasible and may reduce procedural costs by eliminating the need for an Agilis sheath and minimizing device exchanges. The estimated cost saving of approximately USD 2,000 per procedure is primarily attributable to omission of the Agilis sheath, based on institutional procurement pricing. Procedural success was achieved in all cases, with a mean skin-to-skin time of 106 minutes (range: 75-150 minutes) and no procedural complications (Table 1).
Table 1. Baseline characteristics of the patients.
| Age, year | STS score (%) | Cause of BVF | SAPIEN 3 size (mm) | MPG (mmHg) | Procedure time (min) | Cerebral protection | Valve fracture |
| 71 | 3.9 | MR | 29 | 14.8 | 85 | N | N |
| 68 | 2.85 | MR | 26 | 20.3 | 150 | N | Y |
| 75 | 4.35 | MS | 26 | 11.1 | 85 | N | Y |
| 77 | 7.97 | MS | 26 | 17.9 | 80 | Y | Y |
| 87 | 10.8 | MR | 26 | 7.0 | 75 | Y | Y |
| 64 | 2.98 | MS | 26 | 10.3 | 125 | Y | Y |
| 64 | 5.64 | MS | 26 | 19.1 | 115 | Y | Y |
| 55 | 7.04 | MS | 26 | 18.1 | 135 | Y | Y |
BVF, bioprosthetic valve failure; MPG, mean pressure gradient; MR, mitral regurgitation; MS, mitral stenosis.
All procedures achieved satisfactory hemodynamic and echocardiographic results. Nevertheless, the optimal transseptal puncture location is crucial for procedural success, providing the best trajectory for advancing the guidewire, catheters and delivery system through the atrial septum, across the LA, and into the mitral valve.3,4 It should be acknowledged that no direct comparison was performed between this simplified strategy and the conventional Agilis sheath–guided approach in terms of procedural time or complication rates. The Agilis sheath remains an important adjunct that can facilitate ViV-TMVR in selected cases. While adjunctive strategies such as cerebral protection and valve fracture have been explored to optimize ViV-TMVR, procedural simplification — such as eliminating unnecessary devices — may represent an alternative pathway to improving procedural efficiency and cost-effectiveness.
CONCLUSION
ViV-TMVR is a safe and effective treatment for failed bioprosthetic mitral valves. We present a simplified approach that obviates the need for an Agilis sheath and reduces unnecessary device exchanges, streamlining the procedure while maintaining procedural feasibility. This simplified approach may represent a practical alternative workflow in selected patients, particularly in resource-limited settings or when minimizing procedural complexity is desired.
LEARNING POINT
We introduced a technique for a simplified ViV-TMVR without using a steerable sheath.
DECLARATION OF CONFLICT OF INTEREST
All authors have no conflict of interest with respect to the authorship or publication of this article.
REFERENCES
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