title: Successful first-in-man percutaneous transapical-transseptal Melody mitral valve-in-ring implantation after complicated closure of a para-annular ring leak.
abstract: OBJECTIVE
  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.
  
  
  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.
authors.affiliation: Division of Structural and Congenital Heart Disease, Lenox Hill Heart and Vascular Institute, North Shore/LIJ Health System, New York, NY, USA.
authors.forename: Chad
authors.initials: C
authors.lastname: Kliger
authors.forename: Ahmed
authors.initials: A
authors.lastname: Al-Badri
authors.forename: Sean
authors.initials: S
authors.lastname: Wilson
authors.forename: Dillon
authors.initials: D
authors.lastname: Weiss
authors.forename: Vladimir
authors.initials: V
authors.lastname: Jelnin
authors.forename: Itzhak
authors.initials: I
authors.lastname: Kronzon
authors.forename: Gila
authors.initials: G
authors.lastname: Perk
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Fontana
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Ruiz
mesh_terms: D006328:Cardiac Catheterization / Q000379:methods*; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D058386:Mitral Valve Annuloplasty; D008944:Mitral Valve Insufficiency / Q000601:surgery*; D011475:Prosthesis Failure; D055989:Septal Occluder Device