# Mitral Valve-in-Ring Approach for High-Risk Pannus-Related Mitral Stenosis

## TL;DR

A high-risk patient with mitral stenosis due to pannus formation was successfully treated with a transcatheter valve-in-ring procedure, leading to symptom improvement.

## Contribution

This case demonstrates the viability of transcatheter mitral valve-in-ring as a treatment for pannus-related mitral stenosis in high-risk patients.

## Key findings

- A 29 mm Sapien 3 valve was successfully implanted within the mitral ring, resulting in significant symptom relief.
- Follow-up showed a stable valve position with a mean gradient of 4 mmHg and mild mitral regurgitation.
- The patient's NYHA class improved from III/IV to I/II four months post-procedure.

## Abstract

A male patient under follow-up for degenerative mitral regurgitation, treated with a Physio annuloplasty ring two decades earlier, developed progressive shortness of breath and fluid overload, corresponding to New York Heart Association (NYHA) class III/IV. A transoesophageal echocardiogram revealed significant mitral stenosis, with a mean gradient of 11.8 mmHg due to pannus formation around the annuloplasty ring. Surgical repair posed a mortality risk of 25%-35% because of the combined risks of redo surgery, reduced left ventricular systolic function and chronic kidney disease. A transcatheter mitral valve-in-ring (TMViR) procedure was the only feasible option. A 29 mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA) was successfully implanted within the mitral ring. Four months following the procedure, the patient reported significant symptom relief and an improved quality of life (QOL), with a shift to NYHA class I/II. Follow-up echocardiography demonstrated a stable valve position, a mean gradient of 4 mmHg and mild mitral regurgitation. This case highlights TMViR as a viable option for high-risk patients with pannus-related mitral stenosis.