After evaluation and decision by a heart team, procedures were performed under general anesthesia and 2-dimensional and 3-dimensional transesophageal echocardiographic (TEE) guidance. Transseptal puncture was done at the high and posterior part of the fossa ovalis. An Inoue wire (Toray Medical Company, Chiba, Japan) was placed in the left atrium, and septal dilation was performed with Wanda balloons from 12 to 14 mm diameters (Boston Scientific, Galway, Ireland). Then, the mitral valve was crossed with either a Critikon balloon wedge pressure catheter (Arrow International, Inc., Reading, Pennsylvania) or a JR 4 catheter advanced on a 0.035-inch J wire. After placing a J pre-shaped 0.035-inch Amplatz ExtraStiff wire (Cook Medical, Bloomington, Indiana) at the apex of the left ventricle, a pre-dilation of the mitral valve was performed if judged necessary. A 23- or 26-mm SAPIEN XT (Edwards Lifesciences, Inc., Irvine, California) valve was mounted, upside down, on a Novaflex catheter and advanced to the mitral ring. The prosthesis was directed toward the mitral valve by full flexion of the catheter. Then, the SAPIEN XT valve was placed within the mitral ring, its position checked by fluoroscopy and TEE, and deployed by progressive balloon inflation under rapid pacing (160 to 200 beats/min). Post-operatively, patients received a combination of aspirin and clopidogrel for 3 months (then, aspirin alone), or aspirin and oral anticoagulation if indicated. Prosthetic function was assessed according to recommendations (5).