How should I treat recurrent concomitant para-ring and valvular mitral regurgitation after surgical mitral valve repair in a high-risk patient?

BACKGROUND: A 74-year-old male with symptomatic severe recurrent mitral regurgitation after surgical mitral valve repair and high surgical risk was referred for transcatheter mitral valve-in-ring implantation. INVESTIGATION: Two- and three-dimensional transoesophageal echocardiography, fluoroscopy. DIAGNOSIS: After transapical deployment of a 26 mm SAPIEN XT (Edwards Lifesciences, Irvine, CA, USA) in a mitral ring (Physio II ring, size 30; Edwards Lifesciences) and removal of the guidewire, severe para-ring mitral regurgitation originating at the level of the posterior commissure was detected. MANAGEMENT: A 6 mm AMPLATZER (TM) septal occluder system (St. Jude Medical, St. Paul, MN, USA) was implanted at the level of the para-ring dehiscence with significant reduction in para-ring mitral regurgitation. Transthoracic echocardiography pre-discharge showed a mean transmitral gradient of 7 mmHg and minimal mitral regurgitation.