Share this article on:

Transapical Valve-in-Valve-in-Ring for Stenotic Mitral Valve Repair

Dahle, Gry MD*; Rein, Kjell-Arne MD, PhD*; Jönsson, Anders L. MD, PhD

Innovations: Technology & Techniques in Cardiothoracic & Vascular Surgery: September/October 2013 - Volume 8 - Issue 5 - p 376–380
doi: 10.1097/IMI.0b013e3182a6940b
Case Reports

Abstract: A 53-year-old woman, previously treated with irradiation and chemotherapy for Hodgkin lymphoma, was referred for redo valve surgery. She had had a pacemaker implantation and undergone coronary bypass surgery, mitral valve repair with a Carpentier-Edwards 28-mm Physio-annuloplasty ring, as well as a mechanical tricuspid valve replacement and a transfemoral CoreValve 26-mm implantation. She had cardiac cachexia, pleura effusion, and a failed mitral valve repair with stenosis. She was judged inoperable for open surgery but suitable for a transapical valve-in-valve implantation on partial femorofemoral bypass. A 26-mm Edwards SAPIEN XT aortic valve inversely mounted on the Ascendra + delivery catheter was balloon expanded into the Physio ring. During expansion, the introducer sheath remained too deep into the left ventricle and rotated the SAPIEN valve upward to the left atrium, creating the onset of a new mitral regurgitation and retaining the stenosis. Another Edwards SAPIEN XT 26-mm valve was then positioned into the first valve in a “valve-in-valve-in-ring” tandem configuration. Both valves were supported by the Physio ring. The stenosis and the regurgitation were thereafter eliminated.

From the *Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway; and †Kardiologisk Klinikk, Rigshospitalet, Copenhagen, Denmark.

Accepted for publication July 22, 2013.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 12–15, 2013, Prague, Czech Republic.

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Gry Dahle, MD, Department of Cardiothoracic Surgery, Oslo University Hospital, Rikshospitalet, Postboks 4950, Nydalen, 0424 Oslo, Norway. E-mail:;

Mitral valve repair (MVP) with annuloplasty ring is the treatment of choice for many patients with mitral regurgitation, but the repair may fail and the need for reintervention may occur.1,2 The operative risk at reoperation is significantly higher than in the primary operation. This high risk is an incentive for the use of less-invasive techniques such as transcatheter valve implantation. In parallel, the rapidly growing experience with transcatheter aortic valve implantation leads to the consideration of the potential use of the transcathater valve-in-valve replacement after surgical valve implantation in either aortic or mitral positions. In addition, a few case reports and series have suggested the feasibility of transcatheter mitral valve implantation after failure of mitral valve surgery with ring annuloplasty.3–11 We report valve-in-ring for a stenotic mitral annuloplasty.

Back to Top | Article Outline


A 53-year-old woman, treated with irradiation and chemotherapy for Hodgkin lymphoma in 1976, was referred. She had a pacemaker implantation in 1995. She underwent coronary bypass surgery and MVP with the Carpentier-Edwards 28-mm Physio-annuloplasty ring (Edwards Lifesciences Inc, Irvine, CA USA) in 2001. Two years later, she had a mechanical tricuspid valve replacement requiring thrombolysis at a later stage because of valve thrombosis. In 2010, she had a transfemoral transcatheter aortic valve implantation using the 26-mm CoreValve (Medtronic, Minneapolis, MN USA).

At referral, she had cardiac cachexia (46 kg), pleura effusion, and a failed MVP with stenosis, with a mean gradient of 12 mm Hg and pulmonary hypertension (80 mm Hg). The left ventricle was well functioning, but the right ventricular function was somewhat reduced. She was in New York Heart Association functional class III to IV (Fig. 1).

She was judged inoperable but suitable for a transapical valve-in-valve implantation on partial femorofemoral bypass. Computed tomographic reconstructions of the heart using the OsiriX software was done to measure the valve size.

A valve-in-ring operation was done in our hybrid operating room. A small left-sided anterolateral thoracotomy in the fifth intercostal space was performed with the patient under general anesthesia. Two pledget purse-string sutures with Prolene 3-0 were made on the apex of the left ventricle, and peripheral cannulation was prepared in the right femoral artery and vein (Edwards Lifesciences 24F femoral venous cannula and Medtronic EOPA 22F cannula for the artery). A pacing lead to the right ventricle was inserted from the left femoral vein, and a pigtail catheter was inserted for angiography in the left femoral artery. The ACT value was kept at 250 seconds. The apex was punctured with a needle while being on femorofemoral bypass. A soft wire was introduced followed by a multipurpose 6F sheath. Through this, an Amplatzer SuperStiff wire (0.035-in diameter, 1-cm soft tip; Boston Scientific Corp, Natick, MA USA) was positioned through the mitral orifice into the left atrium, aiming for the right upper pulmonary vein. The 24F Ascendra + introducer sheath was advanced through the apex, and no predilation of the valve was done. A 26-mm Edwards SAPIEN XT aortic valve inversely mounted on the delivery catheter was introduced through the mitral ring (Fig. 2A). The sheath was then pulled back. The valve was positioned under the guidance of fluoroscopy and transesophageal echocardiography. Under rapid ventricular pacing, the Edwards SAPIEN XT valve was balloon expanded inside the 28-mm Physio ring. However, the 24F sheath remained too deep into the left ventricle and rotated the SAPIEN valve upward to the left atrium upon deployment (Fig. 2B). The annuloplasty ring could only partially support the expanded valve. On echocardiography, there was a remaining mitral stenosis in addition to the onset of a severe mitral regurgitation (Fig. 3). Another Edwards SAPIEN XT 26-mm valve was thereafter crimped and implanted. This second valve was positioned into the first valve, so the Physio ring could now support both of them (Fig. 4). The stenosis and the regurgitation were eliminated. The echocardiogram showed a mean gradient of 5 mm Hg, no regurgitation, and no obstruction in the LVOT (Fig. 5). The patient was weaned from partial bypass while the introducer sheath was removed and the purse-string sutures were tied. The chest was finally closed (Fig. 6).

After the operation, the patient was in a stable hemodynamic situation and was mobilized. Unfortunately, she developed septicemia and died 23 days postoperatively.

At autopsy (Fig. X), both SAPIEN XT valves were securely fixed into each other supported by the Edwards Physio ring (Fig. 7).

Back to Top | Article Outline


Mitral valve repair is the treatment of choice for mitral valve regurgitation, providing excellent operative results and superior survival and long-term outcomes, as compared with mitral valve replacement. However, postoperative recurrence of mitral valve regurgitation and developing stenosis may occur in some patients.1 In patients with functional mitral valve regurgitation, the prevalence1,2 of recurrent mitral valve regurgitation ranges between 11% and 22%.

The operative risk for reoperation for failed repair or for degenerated bioprosthetic valves significantly outweighs the risks for first-native valve repair or replacement.4 In the presence of comorbidities, these risks increase exponentially. The encouraging results of transcatheter heart valve implantations in general have prompted several experienced centers to explore the feasibility of using these techniques in patients with failed mitral and aortic bioprosthesis. Various successful experiences have recently been reported.3–5

So far, little is known about the feasibility of catheter techniques in patients with failing mitral valve annuloplasty, although it is a growing area. We have previously demonstrated the feasibility of implanting a 29-mm Edwards SAPIEN in a 34-mm Physio ring,10 and Descoutures et al11 have a series of 17 valve-in-ring implantations showing that the procedure is feasible, is safe, and provides short-term improvement of valve function. The misplacement/dislocation of the first valve was due to the introducer sheath remaining too deep into the ventricle. This could easily have been avoided by retracting the sheath. In our case, it was fortunate that the valve-in-valve created a “higher” valve to eliminate the stenosis.

For a practical reason, the lowest ring size to do valve-in-ring procedures for adults should be 26 mm. Rings smaller than that are likely to create to high gradients.

With the aging population, an increasing number of patients may come for primary intervention or reoperation. Consequently, the operative risk will markedly increase because of advanced age or comorbidities.

Back to Top | Article Outline


Valve-in-ring also for stenotic mitral annuloplasties is feasible and safe. The transapical approach facilitates an exact and short way for deployment. No calcium embolization occured. We have also demonstrated that one annuloplasty ring may support two valves. The valve-in-valve in the mitral position does not create any significant pressure gradient, nor does it create any obstruction into the LVOT.

We believe that the valve-in-ring concept in the future may play a significant role in reducing the redo mortality in patients with failed MVPs.

Back to Top | Article Outline


The authors thank their interventional cardiologist Bjørn Bendz for participating in the procedure, anesthesiologist Dr Jan Hovdenes for taking part in the procedure, and echocardiologists Jon Offstad and Kai Andersen for excellent echocardiographic imaging and also all the staff in the intervention center.

Back to Top | Article Outline


1. Ciarka A, Braun J, Delgado V, et al. Predictors of mitral regurgitation recurrence in patients with heart failure undergoing mitral valve annuloplasty. Am J Cardiol. 2010; 106: 395–401.
2. Zhu F, Otsuji Y, Yotsumoto G, et al. Mechanism of persistent ischemic mitral regurgitation after annuloplasty: importance of augmented posterior mitral leaflet tethering. Circulation. 2005; 112: I396–I401.
3. Webb JG, Wood DA, Ye J, et al. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation. 2010; 121: 1848–1857.
4. Gurvitch R, Cheung A, Ye J, et al. Transcatheter valve-in-valve implantation for failed surgical bioprosthetic valves. J Am Coll Cardiol. 2011; 58: 2196–2209.
5. Cheung AW, Gurvitch R, Ye J, et al. Transcatheter transapical mitral valve-in-valve implantations for a failed bioprosthesis: a case series. J Thorac Cardiovsc Surg. 2011; 141: 711–715.
6. Kempfert J, Blumenstein J, Chu MW, et al. Minimally invasive off-pump valve-in-a-ring implantation: the atrial transcatheter approach for re-operative mitral valve replacement after failed repair. Eur J Cardiothorac Surg. 2009; 35: 965–969.
7. De Weger A, Ewe SH, Delgado V, Bax JJ. First-in-man implantation of a trans-catheter aortic valve in a mitral annuloplasty ring: novel treatment modality for failed mitral valve repair. Eur J Cardiothorac Surg. 2011; 39: 1054–1056.
8. Himbert D, Brochet E, Radu C, et al. Transseptal implantation of a transcatheter heart valve in a mitral annuloplasty ring to treat mitral repair failure. Circ Cardiovasc Interv. 2011; 4: 396–398.
9. Casselman F, Martens S, De Bruyne B, Degrieck I. Reducing operative mortality in valvular reoperations: the “valve in ring” procedure. J Thorac Cardiovasc Surg. 2011; 141: 1317–1318.
10. Dahle G, Fiane AE, Rein KA. Transapical 29-mm Edwards SAPIEN-XT aortic valve in a 34-mm mitral annuloplasty ring. Innovations. 2012; 7: 290–294.
11. Descoutures F, Himbert D, Maisano F, et al. Transcatheter valve-in-ring implantation after failure of surgical mitral repair. Eur J Cardiothorac Surg. 2013; 44: e8–e15.

Stenotic mitral valve repair; Valve-in-ring; Valve-in-valve

©2013 by the International Society for Minimally Invasive Cardiothoracic Surgery