An 83 year old lady presented with NYHA III symptoms. She had a background of mitral valve repair with Seguin Annuloplasty Ring size 28 for severe mitral regurgitation due to ruptured chordae at P2/P3 segment. Her other past medical history included diabetes mellitus , atrial fibrillation on warfarin and hypertension. 

Blood tests showed NTProBNP of 3629. ECG showed AF with QRS 92ms. Transthoracic echocardiogram showed LVEF of 56%, P2 prolapse with ruptured MV chordae with flail posterior leaflet. There was severe eccentric MR, mean trans-mitral gradient of 6.5mmHg. Coronary angiogram showed mild CAD. Her STS mortality score for MVR was 12%. Heart Team concluded that patient was deem surgically inoperable and suggested for TMVR. CT analysis showed NeoLVOT area of only 135mm^2 and a high risk of LVOTO.   

Pre-emptive alcohol septal ablation was performed. S1 distal branch was selected after sonovue mapping instead of S2. Runthrough EF inside OTC 2.0 x 15mm was used. A total of 1.5cc alcohol was injected. Post ASA resulted into complete heart block and a leadless pacemaker was inserted. After 4 weeks, repeated CT showed adequate NeoLVOT area of 282mm^2, and hence decided to proceed for TMVR. Also the ring was radiolucent, there was no fluoroscopic marker, and so additional measures were required.

We obtained the transeptal access at height 3.7cm, inferior-posterior under TEE guidance using SL1, BRK-1 needle. Then exchanged to a super-stiff wire and a long J wire to insert a 5Fr pigtail for LA angiogram, then inserted the 14Fr E sheath, and followed by a medium curl Agilis 8.5Fr into LA. Next, we performed the LV wire snaring by inserted JL 3.5 7Fr guiding catheter through left femoral arterial access, with inside a 18-30 Ensnare inserted. Over the Agilis Sheath, a 6Fr pigtail crossed the Memo 4D mitral valve ring. The pigtail was then snared by the JL guiding catheter from arterial side, then the pigtail was exchanged to a preshaped Confida wire into left ventricle. 
Balloon septostomy was then performed using a 14mmx40cm Armanda balloon. Balloon predilatation to determine the waist of the ring, LA angiogram and live biplane TEE guidance were used to guide as a roadmap for the TMVR deployment. A Sapien 26mm(+1cc) was prepared and deployed under rapid pacing at 180bpm with optimal depth (20 LA/80 LV) successfully. 
Iatrogenic ASD was then closed with a 16mm Amplatzer ASD device with no residual leak. 

In conclusion, TMVR valve-in-ring procedure was safe and effective after pre-emptive ASA. An accurate pre CT planning was crucial in achieving a satisfactory outcome. Also, despite the radiolucency of the mitral ring, balloon pre-dilatation, LA angiogram and TEE guidance all gave additional insights and a road to success for the accurate TMVR deployment.