Transcatheter mitral valve implantation in severely calcified rheumatic mitral stenosis without annular calcification

An 80-year-old female was admitted for acute decompensated heart failure (NYHA Class IV). Echocardiography revealed severe mitral stenosis (MS, anatomical area = 0.5 cm2) with moderate regurgitation (Panels A–B, see Supplementary material online, Video S1), moderate aortic stenosis (peak velocity = 3.3 m/s, mean pressure gradient, PG = 23 mmHg), and severe tricuspid regurgitation, suggesting rheumatic valve disease. Percutaneous mitral commissurotomy was contraindicated due to concomitant moderate mitral regurgitation. Surgical risk was deemed prohibitive (Society of Thoracic Surgeon score 18.9%). The possibility of transcatheter mitral valve implantation (TMVI) was evaluated with CTA, which showed no mitral annular calcification (MAC) but extensively thickened mitral leaflets with severe bicommissural calcification extending to A1–P1 and A3–P3 segments (see Supplementary material online, Video S2). On reformatted short-axis view, the area demarcated by the calcification arch was 444.7 mm2 (Panel C). The predicted early-systolic neo-left ventricular outflow tract area was 382.3 mm2 (Panel D). The team therefore decided to proceed with TMVI with surgical backup. A 26 mm balloon-expandable PrizValve (NewMed Medical Inc., Shanghai, China) was implanted via the trans-septal approach (Panel E, see Supplementary material online, Video S3). Post-implant angiography (Panel F, see Supplementary material online, Video S4) and transesophageal echocardiography (Panel G, see Supplementary material online, Video S5) showed stably positioned well-functioning bioprosthesis (mean PG = 2 mmHg) with trivial periprosthetic regurgitation. Post-CTA (Panel H) and serial echocardiography confirmed prosthesis stability and function before discharge.