Valve-in-Ring TMVR Following Antegrade Base-to-Tip LAMPOON With ELASTIC on VA-ECMO Support: A Case Report.

Transcatheter mitral valve replacement (TMVR) in failed surgical rings with an Alfieri stich represents a therapeutic challenge. A 70-year-old man with prior robotic surgical mitral valve repair with an incomplete ring and an Alfieri stich presented with acute decompensated heart failure and was found to have severe mitral regurgitation and pulmonary hypertension. He was deemed not to be suitable for redo surgery. Preprocedural computed tomography demonstrated anterior mitral leaflet length of 29 mm, indicative of high-risk for dynamic left ventricular outflow tract obstruction. This case described the successful combination of antegrade laceration of the anterior mitral valve leaflet to prevent outflow obstruction and electrosurgical laceration of Alfieri stitch to facilitate valve-in-ring TMVR while on venoarterial extracorporeal membrane oxygenation support to prevent hemodynamic compromise during high-risk valve-in-ring TMVR.