Failed transcatheter mitral valve-in-ring implantation followed by transapical valve-in-valve within the ring and ad hoc paravalvular leak closure

There is a rapid emergence of transcatheter mitral valve-invalve (TMVIV) and valve-in-ring (TMVIR) techniques as an alternative to the conventional surgical valve replacement in ineligible patients requiring repeat surgery (1).The selection of a new transcatheter heart valve (THV) for degenerated surgical valves is relatively simple; however, the selection of valves for mitral rings is more nuanced because the rigidoval or D-shaped rings will not conform to the round shape of theprosthesis, thus posing a high risk of paravalvular leak (PVL).Although prior reports have described simultaneous TMVIVand percutaneous PVL closure techniques, our case report provides the first description of simultaneous transapical valve-invalve implantation and the closure of severe PVL after a failedtransseptal valve-in-ring procedure (2, 3).