Transcatheter Mitral “Valve-in-Ring” Implantation: A Word of Caution

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Transcatheter Mitral “Valve-in-Ring” Implantation: A Word of Caution Ricardo Allende, MD, Daniel Doyle, MD, Marina Urena, MD, Henrique B. Ribeiro, MD, Ignacio J. Amat-Santos, MD, Mathieu Bernier, MD, Sergio Pasian, MD, Robert DeLarochellière, MD, Eric Dumont, MD, Josep Rodés-Cabau, MD The Annals of Thoracic Surgery Volume 99, Issue 4, Pages 1439-1442 (April 2015) DOI: 10.1016/j.athoracsur.2014.06.083 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Echocardiographic two-dimensional and three-dimensional images showing (A) a dysfunctional mitral homograft with severe insufficiency and (B) stenosis and (C) the oval shape of the mitral ring. Fluoroscopic images showing (D) a severely calcified aortic valved conduit with (E) severe aortic regurgitation. Computed tomographic volume-rendered images and reconstructions showing (F) severe calcification of the aortic valved conduit, (G) dimensions of the aortic annulus, (H, I) inner and outer diameters of the mitral ring, (J) the saddle shape of the mitral ring, and (K) the presence of severe peripheral vascular disease. The Annals of Thoracic Surgery 2015 99, 1439-1442DOI: (10.1016/j.athoracsur.2014.06.083) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Fluoroscopic images showing (A, B) steps of TMViRI and (C, D) aortic valve-in-valve implantation: (A) Note the incomplete filling and the waist in the middle of the balloon during mitral valve deployment suggesting excessive oversizing of the prosthesis and (B) the unchanged oval shape of the mitral ring after transcatheter valve implantation. (C) Implantation of the aortic prosthesis with the complete expansion of the balloon and (D) absence of aortic regurgitation. The Annals of Thoracic Surgery 2015 99, 1439-1442DOI: (10.1016/j.athoracsur.2014.06.083) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Echocardiographic 2D and 3D images showing results of transcatheter mitral valve-in-ring implantation. (A) Note the moderate mitral regurgitation with (B, C) three mitral leaks (two paravalvular and one central) and (D) the oval shape of the transcatheter valve. The Annals of Thoracic Surgery 2015 99, 1439-1442DOI: (10.1016/j.athoracsur.2014.06.083) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 (A) Incomplete expansion of the transcatheter valve prosthesis in situ and (B) its oval shape to conform to the mitral ring, after explantation. (B) Note the unchanged oval contour of the mitral ring. The Annals of Thoracic Surgery 2015 99, 1439-1442DOI: (10.1016/j.athoracsur.2014.06.083) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions