Challenging Case of Transcatheter Mitral Valve-in- Valve-in-Valve Replacement

Objective: Unusual clinical courseBackground: A 39-year-old man with a complex valvular history of recurrent methicillin-resistant Staphylococcus aureus en-docarditis with 2 surgical mitral valve replacements (in 2016 and 2017) followed by transcatheter mitral valve replacement (in 2019) presented with orthopnea, paroxysmal nocturnal dyspnea, chest pain, cough, and pro-gressively worsening dyspnea on exertion.Case Report: Extensive workup was performed, including transesophageal echocardiogram, which revealed a malfunction-ing, severely stenotic bioprosthetic valve. Left and right heart catheterization revealed mild non-obstructive coronary artery disease and severe pulmonary hypertension. Given the patient's complex medical history, he was deemed to be at an elevated risk for repeat sternotomy and repeat valve replacement surgery. Therefore, he underwent a percutaneous transcatheter mitral valve replacement with a 26-mm SAPIEN 3 Edwards valve placed within the previous 29-mm SAPIEN valve. Post-procedural imaging revealed a well-placed valve with an improved mitral valve gradient. Conclusions: This is one of the few rare cases of mitral valve-in-valve via a transcatheter mitral valve replacement approach with successful deployment of a SAPIEN 3 tissue heart valve. The patient experienced significant reversal of heart failure symptoms and improved exertional tolerance following deployment of the valve and was eventu-ally discharged home in a stable condition.