case_images: PMC11694682_01
case_images: Mitral regurgitation at baseline as assessed by transesophageal echocardiogram.
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case_images: The echocardiogram showed good left ventricular function (left ventricular ejection fraction, LVEF = 60%) with mild-to-moderate aortic stenosis, severe mitral steno-insufficiency (transvalvular mean gradient = 5 mmHg, effective regurgitant orifice area 0.45 cm2, vena contracta 0.8 cm) with severe MAC, and severe tricuspid regurgitation (Figure 1).
case_images: Procedural planning with computed tomography scan and assessment of neo-left ventricle outflow tract of 329 mm2 (indicated by the area with number 2).
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case_images: Consequently, the patient was screened for transvenous-transseptal percutaneous valve-in-MAC with computed tomography (CT) scan and deemed suitable for the procedure (Figure 2): in particular, calcium burden and distribution were assessed with a total MAC score of 9 points together with neo-LVOT simulation.
case_images: Implantation of prostheses in mitral position.
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case_images: After transseptal puncture in the posterior-inferior quadrant of the fossa ovalis, the patient underwent successful TMVI with Sapien 3 Ultra 29 mm (Edwards Lifesciences, USA) (Figure 3).
case_images: Residual paravalvular leak in 2D echocardiogram.
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case_images: In addition, due to significant residual paravalvular leak (PVL), a plug (Amplatzer Valvular Plug III, AVP III, Abbott, USA) was implanted (Figures 4 and 5).
case_images: Residual paravalvular leak in 3D echocardiogram.
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case_images: In addition, due to significant residual paravalvular leak (PVL), a plug (Amplatzer Valvular Plug III, AVP III, Abbott, USA) was implanted (Figures 4 and 5).
case_images: Plug snaring.
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case_images: III embolized requiring recapture with the snare (Figure 6). It was finally successfully implanted at second attempt (Figure 7).
case_images: Plug implantation.
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case_images: III embolized requiring recapture with the snare (Figure 6). It was finally successfully implanted at second attempt (Figure 7).