Mitral valve-in-valve with severe atrial septum calcification

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A 55-year-old woman with an incomplete atrioventricular canal, who underwent repair of the mitral cleft and patch closure of the ostium primum type defect, followed by mitral bioprosthesis implantation (Carpentier PERIMOUNT 27, Edwards, United States) in adulthood. She developed episodes of left atrial flutter. Due to the inability to perform a transseptal puncture, we proceeded with retroaortic atrioventricular node ablation, resulting in iatrogenic left main coronary artery dissection, which resolved after drug-eluting stent implantation (figure 1A-D, videos S1 and S2). During follow-up, she showed signs of progressive prosthetic degeneration (figure 2A-B, videos S3 and S4), which led to transcatheter mitral valve-in-valve implantation. We performed a transseptal puncture of the severely calcified patch (figure 2C-D) using a Versacross system (Boston Scientific, United States). Then, we used a deflectable catheter to advance a high-support guidewire, which was, eventually, captured in the left ventricle, establishing a venoarterial loop. Afterwards, we performed a septostomy with an Atlas Gold 16 mm × 45 mm balloon catheter (BD, United States) and with great difficulty given the anatomical complexity, we advanced a 26-Fr DRYSEAL sheath (Gore, United States) into the left atrium through which we implanted a SAPIEN 3 Ultra 26 bioprosthesis (Edwards, United States) with a...

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