Transcatheter Mitral Valve-in-Ring Implantation in the Flexible Adjustable Attune Annuloplasty Ring.

Transcatheter mitral valve-in-ring implantation (TMViR) poses unique challenges when compared to valve-in-valve implantation due to the large variation in the different annuloplasty rings used. Annuloplasty rings are often classified according to whether they are complete or incomplete, rigid, semi-rigid, or flexible, and whether their three-dimensional geometry is saddle-shaped or flat. A limited number of annuloplasty rings are available which are adjustable allowing the surgeon to increase or decrease the size of the ring once it has been sutured in place. To our knowledge there has been no description of TMViR in such adjustable complete rings and recommendations on THV sizing and implantation are not available on the Valve-in-Valve application. Here we report a case of TMViR in an adjustable annuloplasty ring (Attune ring, Abbott, Chicago, IL, USA) and review the literature on TMViR.