Percutaneous Mitral Valve-in-Ring Procedure in a Case of Severe Mitral Regurgitation Repaired with a Surgical Flexible Ring: A Step-by-Step Description.

Severe mitral regurgitation (MR) following surgical repair of the mitral valve poses a significant clinical challenge. Patients who have undergone surgery are typically at high risk for a second operation. This report details the case of a 54-year-old male who underwent aortic valve replacement and mitral valve repair using a 34-ring, 14 years prior. The patient presented with severe MR, severe left ventricular (LV) dilation, and a reduced ejection fraction of 20%. A Sovering 34 ring, characterized by its oval, radio-opaque, and flexible nature and completely encircling the annulus, was used. After comprehensive assessment utilizing cardiac computed tomography (CT) and the Valve-in-Valve (ViV) application, a 32 mm balloon-expandable transcatheter heart valve was chosen. The selected valve was the 32 mm Myval (Meril) valve, the largest size available globally. Following careful alignment (left atrium/left ventricle ratio (LA/LV) ratio 20/80) and under rapid pacing, the valve was successfully implanted within the ring. Subsequent transesophageal echocardiography confirmed the valve's functionality, and left ventriculography showed no paravalvular regurgitation. The Mitral Valve-in-Ring (MVIR) procedure emerges as a promising therapeutic option for patients with a history of mitral valve repair and severe MR. This procedure is preferred in centers where structural heart interventions are performed by an experienced team.