A 61-year old caucasian woman was admitted for progressive worsening dyspnea of grade III to IV associated with frequent episodes of palpitations. The patient had a history of mild mitral steno-regurgitation, diagnosed 15 years before. A transesophageal echocardiogram revealed the presence of severe mitral valve regurgitation (4+/4+) associated with moderate stenosis (medium gradient 9-10 mmHg, maximum gradient 22 mmHg, valvular area 1,5 cm2). Severe calcification of the posterior portion of the annulus, extending to the postero-lateral wall and to the posterior mitral valve leaflet was also described. The mitral chordae were heavily calcified and shortened, with reduction of inter-chordal space. Moderate tricuspid regurgitation due to annular dilatation was also found. The massive degree of calcification extending to both the valvular and subvalvular mitral apparatus would have rendered both valve repair and substitution technically challenging, so it was decided to proceed with the implantation of an Edwards Sapien aortic valve in the mitral position (n°26). Because of the presence of a perivalvular leak after positioning of the valve, a patch of bovine pericardium was sutured to the valve and to the atrial base. Tricuspid insufficiency was treated by placing an incomplete Contour 3D n°26 ring. Aortic crossclamp and cardiopulmonary bypass times were 118 and 145 mins respectively. Weaning from bypass did not pose any complications and the patient was transferred to the intensive care unit. The postoperative course was uneventful and the patient was dismissed after a two-week hospital stay with a predischarge transthoracic echocardiogram showing a correctly positioned mitral prosthesis with normal gradients (mean gradient 5 mmHg).
To the best of our knowledge, the placement of an Edwards Sapien aortic valve (generally used for TAVI procedures) in the mitral position has not yet been reported: further investigation seems warranted because this may represent a possible solution to these complex cases. Further follow up of this patient is needed to demonstrate the durability of the implanted valve and confirm the absence of technical complications.