First-in-Man Percutaneous Transseptal Closure of Paravalvular Regurgitation After Percutaneous Valve-in-Ring Implantation.

A 73-year-old man with permanent atrial fibrillation, coronary artery disease revascularized with coronary artery bypass grafting, mitral valve repair with a 30-mm Carpentier Physio ring (Edwards Lifesciences, Irvine, California), tricuspid valve repair with a 34-mm Edwards MC3 ring (Edwards Lifesciences), and implantation of a 23-mm CarboMedics aortic valve (Sorin Group, Milan, Italy) in 2008 was admitted because of recurrent congestive heart failure secondary to severe mitral regurgitation that was due to mitral ring dysfunction. Associated comorbidities included thrombocytopenia and chronic renal failure. The patient was not considered a surgical or MitraClip (Abbott Laboratories, Chicago, Illinois) candidate by the heart team. Transcatheter mitral valve-in-ring (ViR) was considered the most suitable treatment. Using a transseptal approach over a venoarterial loop, a 29-mm Edwards SAPIEN XT valve (Edwards Lifesciences) was correctly implanted within the mitral ring (Figure 1A); however, echocardiography demonstrated significant paravalvular regurgitation between the ring and the valve (Figure 1B). Balloon post-dilation was not considered an option because of the risk of para-ring dehiscence or distortion of the ring. Percutaneous closure of the leak was scheduled. A 5 7-mm leak was measured by 3-dimensional transesophageal echocardiogram. After transseptal