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

## TL;DR

This case describes a rare complication during a heart valve procedure where a prosthetic ring detached, causing injury and requiring emergency surgery.

## Contribution

The paper highlights a rare complication of TMVR in patients with prior surgical repairs, emphasizing procedural risks and outcomes.

## Key findings

- Prosthetic ring detachment occurred during TMVR due to partial dehiscence from balloon valvuloplasty or imaging oversight.
- The complication led to native annular tearing, prosthesis migration, and hemodynamic collapse requiring open surgery.
- Prosthesis misalignment in TMVR can cause annular stress, embolization, and cardiac tamponade, often needing emergency intervention.

## Abstract

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.

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.

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.