Successful first-in-man percutaneous transapical-transseptal Melody mitral valve-in-ring implantation after complicated closure of a para-annular ring leak

AIMS: Transcatheter techniques can theoretically be applied to the treatment of para-annular ring (PAR) leaks. Little is known about their potential application and resultant complications in such cases. We describe the first-in-man percutaneous transapical-transseptal Melody valve-in-ring (ViR) implantation after a complication from percutaneous PAR leak closure. METHODS AND RESULTS: A 49-year-old woman, at high operative risk, presented with congestive heart failure secondary to severe para-ring/extravalvular regurgitation two months after bypass surgery and mitral ring annuloplasty. Successful percutaneous closure of the leak was performed using an AMPLATZER Vascular Plug IV. One month later, she developed haemolysis with severe PAR regurgitation, through and around the device. After device retrieval and placement of an AMPLATZER Muscular VSD occluder, the patient developed severe intravalvular regurgitation. Completely percutaneous, transseptal delivery of a Melody ViR was performed over a transapical-transseptal, arteriovenous rail. Echocardiography revealed trivial residual regurgitation through the implanted valve with mild transvalvular gradients. CONCLUSIONS: Percutaneous closure of mitral PAR leaks after ring annuloplasty in the high-risk patient is feasible (proof-of-concept), particularly when the leak is para-ring/extravalvular. Potential complications include severe intravalvular mitral regurgitation caused by disruption of the mitral apparatus and/or ring deformation during device deployment, which can be successfully treated via percutaneous transapical-transseptal ViR implantation.