Percutaneous Mitral Valve in Ring (MVIR) Procedure in a Case of Severe Mitral Regurgitation Repaired with a Surgical Flexible Ring and a Step-By-Step Description of The Procedure

Severe mitral regurgitation (MR) following surgical repair of the mitral valve presents a significant clinical challenge. Since the patient has undergone surgery, a second operation usually carries a high risk in these patients. Our case is a 54-year-old male who underwent aortic valve replacement and mitral valve repair, utilizing a 34-ring, 14 years ago. The patient presented with severe MR, accompanied by severe left ventricular (LV) dilation and a reduced ejection fraction of 20%. A Sovering 34 ring was used characterized by its oval, radio-opaque and flexible nature. It was completely encircling the annulus.After a comprehensive assessment, utilizing cardiac CT findings and the Valve-in-Valve (ViV) application, a decision was made to use a 32mm balloon-expandable transcatheter heart valve. The selected valve was the 32mm Myval (Meril) valve, which is the largest size available globally. Following careful alignment (LA/LV ratio 20/80) and under rapid pacing, successful valve implantation within the ring was achieved. Subsequent transesophageal echocardiography showed well functioning valve. On left ventriculography no paravalvular regurgitation was noted. Mitral Valve in Ring (MVIR) emerges as a promising therapeutic option for patients with a history of mitral valve repair and severe MR. This procedure can be preferred in centers where structural heart interventions are performed by an experienced team.