From Repair to Replacement: Ring Detachment and Secondary Annular Injury During Transcatheter Mitral Valve-in-Ring Procedure.

OBJECTIVE

The present case portrays an infrequent complication of transcatheter mitral valve replacement (TMVR) in a patient with a previous surgical mitral valve repair with ring annuloplasty and an Alfieri stitch, who developed mitral stenosis and heart failure.

KEY STEPS: After transseptal puncture, balloon atrial septostomy and mitral balloon valvuloplasty were performed. The transcatheter valve was positioned and deployed through a partial dehiscence on the anterior aspect of the prosthetic ring, probably caused by the balloon valvuloplasty or undetected in the preprocedural imaging assessment. This led to prosthetic ring detachment and dislocation, native annular tearing, migration of the transcatheter prosthesis, and subsequent hemodynamic collapse requiring open surgery.

POTENTIAL PITFALLS: In TMVR, prosthesis misalignment or malposition may cause annular stress during deployment and tearing of the native annulus, prosthesis embolization from suboptimal anchoring, and cardiac tamponade from left ventricular rupture, often requiring emergency surgical intervention.