Atrial lead entanglement during transcatheter mitral valve-in-ring implantation in patient with dual-chamber implantable cardioverter-defibrillator: case report

Background: Ring annuloplasty failure after mitral valve repair frequently occurs after long-term follow up. Valve-in-ring transcatheter mitral valve replacement (TMVR) is an emerging therapeutic option for this high surgical risk condition. While a dual-chamber implantable cardioverter-defibrillator (ICD) is frequently utilized for sudden cardiac death prevention in this population, valve-in-ring TMVR intraprocedural difficulty associated with atrial lead presence is rarely known. Case summary: A 76-year-old male, with history of coronary artery bypass graft surgery and mitral ring annuloplasty experienced recurrence of severe mitral regurgitation. Due to high surgical mortality risk and unsuitable anatomy of mitral valve for transcatheter edge-to-edge repair, this patient underwent mitral valve-in-ring TMVR. Using transvenous-transseptal access, a 26 mm SAPIEN-3 prosthetic valve was delivered to the mitral area. However, as the patient has a history of dual-chamber ICD, a prosthetic valve cannot pass through during delivery, due to atrial lead entanglement. To overcome this difficulty, atrial septum balloon dilatation manoeuvre was done to facilitate valve delivery, which resulted in successful prosthetic valve delivery and deployment at the mitral position with satisfactory results. Discussion: Valve delivery difficulty due to atrial lead entanglement can occur during valve-in-ring TMVR in patients with dual-chamber ICD implantation history. Atrial septum balloon dilatation can be performed to overcome this problem.