Transvenous mitral valve replacement after failure of surgical ring annuloplasty.

To the Editor: Mitral valve repair is the preferred treatment for itral regurgitation (MR). However, failure or recurrence of MR ight occur. Re-operation might carry a high risk in patients with omorbidities. A few reports have suggested the feasibility of ranscatheter mitral valve replacement after failure of surgical ring nnuloplasty (1–4). We report here the first series of transvenous itral valve-in-ring implantation (TVIR). After evaluation and decision by a heart team, procedures were erformed under general anesthesia and 2-dimensional and -dimensional transesophageal echocardiographic (TEE) guidnce. Transseptal puncture was done at the high and posterior part f the fossa ovalis. An Inoue wire (Toray Medical Company, hiba, Japan) was placed in the left atrium, and septal dilation was erformed with Wanda balloons from 12 to 14 mm diameters Boston Scientific, Galway, Ireland). Then, the mitral valve was rossed with either a Critikon balloon wedge pressure catheter Arrow International, Inc., Reading, Pennsylvania) or a JR 4 atheter advanced on a 0.035-inch J wire. After placing a pre-shaped 0.035-inch Amplatz ExtraStiff wire (Cook Medical, loomington, Indiana) at the apex of the left ventricle, a preilation of the mitral valve was performed if judged necessary. A 3or 26-mm SAPIEN XT (Edwards Lifesciences, Inc., Irvine, alifornia) valve was mounted, upside down, on a Novaflex atheter and advanced to the mitral ring. The prosthesis was irected toward the mitral valve by full flexion of the catheter. hen, the SAPIEN XT valve was placed within the mitral ring, its osition checked by fluoroscopy and TEE, and deployed by rogressive balloon inflation under rapid pacing (160 to 200 eats/min). Post-operatively, patients received a combination of spirin and clopidogrel for 3 months (then, aspirin alone), or spirin and oral anticoagulation if indicated. Prosthetic function as assessed according to recommendations (5). From March 2011 to February 2012, 6 high-risk patients nderwent TVIR (Table 1). Pre-dilation of the mitral valve was erformed in 2 patients with mitral stenosis and commissural usion. In all the cases, prostheses were implanted in an adequate osition, with no major complication. Mean hospital stay duration as 9 5 days. No patient had more than mild paravalvular regurgitation. One patient had a “significant” residual stenosis, and 2 had a “possible” stenosis (5). In 3 cases, a dynamic gradient was observed in the left ventricular outflow tract, due to the displacement of the subvalvular apparatus. No significant inter-atrial shunt was observed. Although the rings became more circular after prosthesis implantation, their shape was not fully circumferential. At discharge, all patients were in New York Heart Association functional class II. Patient 1 was readmitted 1 year after TVIR for the progression of aortic stenosis and successfully underwent transcatheter aortic valve implantation. Patients 2 and 6 had congestive heart failure due to multifactorial causes and improved with medical therapy. At last follow-up (mean: 5 4 months), 5 patients were in