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Objectives:
The incidence of redo surgery for degenerated bioprosthesis is expected to increase. The operative mortality and morbidity for these patients, presenting with additional comorbidities is high. The transcatheter valve-in-valve implantation might offer a promising alternative therapeutic approach for high-risk patients. In the present report, we describe the case of a successful transcatheter valve implantation in biological mitral valve prosthesis under sight, combined with a thrombectomy of the right atrium.

Methods:
A 78 years old, frail woman presented with dyspnoea at rest and NYHA IV. She had a history of two myocardial infarctions with subsequent PTCA of the LAD, biological mitral valve replacement and surgical closure of a coronary-pulmonary fistula in 2001. 4 years later the patient underwent biological aortic valve implantation for aortic valve stenosis and a thrombectomy of the left atrium. Under Coumadin therapy, she developed cerebral bleeding and insult with a persisting neurological deficit. Preoperatively, a severe dysfunction of the biological prosthesis in the mitral valve, as well as thrombus masses occluding one third of the left atrial cavity, were found. The logistic EuroScore was 17.05 %, the STS Score 8.7%.

Results:
The patient underwent a successful transcatheter mitral valve-in-valve implantation and left atrial thrombectomy. Postoperative echocardiographic examination confirmed a good prosthesis positioning and haemodynamic function. The postoperative course was uneventful except the need for pacemaker implantation due to bradycardic atrial fibrillation and a prolonged hospital stay due to wound infection. 8 month after the operation the patient is free of any cardiac symptoms and presents in NYHA class II.


Conclusion:

Transcatheter heart valve implantation integrated in the open heart surgery is a promising approach to reduce the aortic clamp time and to reduce the surgical risk in high risk patients undergoing redo surgery.