Transcatheter aortic valve implantation is now a mainstay of treatment in patients with aortic stenosis who are considered intermediate, high and prohibitive risk for surgery. Extended use of this innovative platform in treating other conditions has led to its approval in treating degenerated aortic bioprosthesis. Similarly, use of transcatheter devices in treating degenerated mitral bioprosthesis and failed mitral valve repairs with annuloplasty rings has opened a potential alternative to surgery in these patients. Experience in mitral valvein-valve (MVIV) and valve-in-ring (VIR), while still limited, is on the rise. Although similar in many ways to the aortic VIV, it is different with respect to patient selection, planning and procedural steps. Familiarity with the bioprosthetic properties and dimensions can help an operator choose an appropriate transcatheter device and deploy it in an ideal position. Due to greater variability in construction and properties, mitral rings have led to poorer results compared to mitral valve-in-valve. Understanding the properties of mitral rings is critical and has been simplified by us in a stepwise manner. We also describe steps in patient preparation and procedure, which should help operators in performing this procedure. Certain unique complications, such as left ventricular outflow tract obstruction and risk of embolization, are discussed with tips to address these issues. Once these steps are followed, the procedure can be performed with minimal risk and good outcome.

Background While each scleral fixation method has its own advantages, there is a lack of strong evidence to suggest a superior technique. Advances in cataract surgery expand patient eligibility for successful cataract extraction, benefitting a growing population of pseudophakic patients. However, implantation of secondary intraocular lens (IOL) with compromised anterior or posterior capsule is a more challenging task. Each method of scleral fixation has its own advantages and none of them has strong evidence to be superior. This paper describes postsurgical outcomes of two scleral intraocular(IOL) fixation techniques combined with pars plana vitrectomy(PPV) from a single tertiary referral eye center. Methods Patients underwent PPV and IOL implantation with either four-point sutured scleral fixation (Akreos AO60(AK); n = 24) or two-point sutureless flanged intrascleral fixation (CT Lucia(CTL); n = 7). Reports include IOL and sclerotomy placement, fixation techniques, and IOL model. Results Thirty-one eyes of thirty patients were analyzed. Average change in vision from baseline measurement was LogMAR − 0.68 ± 0.66 and − 0.90 ± 0.63 for AK and CTL groups, respectively. Average postoperative refractive error was − 0.3 ± 1.03 D (AK) and 0.4 ± 0.60 D (CTL). No opacification cases of Akreos lens were found in this study with the longest follow up of 53 months. Conclusions Both methods of implantation (sutured and sutureless) could provide good visual and refractive outcomes. Minimal complication rates were reported despite including patients with multiple comorbidities, making both techniques an attractive choice for secondary IOL implantation.

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Video clip is available online.Transcatheter aortic valve replacement (TAVR) has shown astounding success, resulting in its rapid adoption and widespread use. 1 Given the positive impact of TAVR, efforts unsurprisingly shifted to address mitral valve pathology with transcatheter techniques. Untreated severe symptomatic mitral regurgitation (MR) reaches a mortality rate of 50% at 5 years of follow-up and has an estimated prevalence of 2-4 million people in the United States. 2,3 MR is agedependent, with global prevalence increases from 1.7% to 10% in individuals age >75 years. 4 A large proportion of patients with MR are not ideal candidates for surgical intervention and may benefit from transcatheter options.Emerging options to address MR can be divided into transcatheter mitral valve repair (TMVr) and transcatheter mitral valve replacement (TMVR) technologies. TMVr addresses abnormalities of one of the components of the mitral valve apparatus, such as correcting annular dilatations, abnormal leaflet coaptation, and chordae pathology. Among the TMVr technologies, the greatest clinical experience is with the MitraClip device (Abbott Vascular, Santa Clara, Calif), which is approved for high-risk primary and secondary MR patients. 5,6 However, TMVr generally reduces MR rather than eliminates MR. Alternatively, TMVR can eliminate MR independent of the pathology and may offer a promising alterative for patients with contraindications to surgery. 5 Although attractive in concept, the development of TMVR faces many challenges-anatomic and physiological, pathological, and device design and access routes. ANATOMIC AND PHYSIOLOGICAL CHALLENGESCompared with the aortic valve, the mitral valve is a large, noncircular and dynamic structure (Figure 1, A). Unlike in aortic stenosis, the mitral annulus is typically not calcified and contains sections of myocardial and fibrous tissue that limit structural support to secure the device. With exposure to higher pressure during closure (systolic blood pressure), secure fixation of the device is critical (Figure 1, B). Once the TMVR is implanted, the anterior mitral leaflet can become pinned open toward

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