Late mitral annuloplasty failure: the loss of the ring

Successful first-in-man Melody transcatheter valve implant in a dehisced mitral annuloplasty ring transapical valve-in-ring implant

AIMS

A "valve-in-ring" (ViR) procedure involves the transcatheter implant of a valved stent in a prosthetic mitral ring. The presence of a partial dehiscence of the prosthetic ring is a major contraindication for a ViR due to inefficacious sealing. We describe an alternative method of ViR implant to achieve proper valve sealing in the case of ring dehiscence.

METHODS AND RESULTS

A 76-year-old male patient suffered from severe central mitral regurgitation due to annuloplasty ring dehiscence and leaflet tethering. ECG-gated multidetector computed tomography was used for preoperative planning. Standard transapical access was gained through a minimally invasive left thoracotomy in the 5th intercostal space. A customised Melody valve with two PTFE sutures fixed to the apex was used. The intervention was performed without complications, the patient recovered well, and transthoracic echo revealed no mitral regurgitation through the implanted valve with a transvalvular gradient of 4 mmHg.

CONCLUSIONS

The implantation of a long covered stent such as the Melody valve allows successful sealing following a ViR even in case of partially detached annuloplasty rings. This procedure is a proof of concept that proper sealing can be achieved at the leaflet level without the use of radial force at the annular level.