Norihiro Kondo, MD, Takashi Shuto, MD, Jeremy R. McGarvey, MD, Kevin J

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Melody Valve-in-Ring Procedure for Mitral Valve Replacement: Feasibility in Four Annuloplasty Types Norihiro Kondo, MD, Takashi Shuto, MD, Jeremy R. McGarvey, MD, Kevin J. Koomalsingh, MD, Manabu Takebe, MD, Robert C. Gorman, MD, Joseph H. Gorman, MD, Matthew J. Gillespie, MD The Annals of Thoracic Surgery Volume 93, Issue 3, Pages 783-788 (March 2012) DOI: 10.1016/j.athoracsur.2011.12.021 Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Fluoroscopic images of the 4 types of annuloplasty rings used for the Melody valve-in-ring procedure, including the following: (A) complete rigid rings; (B) partial rings; (C) saddle rings; and (D) flexible rings. Photos of each ring are shown in the insets. The Annals of Thoracic Surgery 2012 93, 783-788DOI: (10.1016/j.athoracsur.2011.12.021) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Transvenous, transseptal approach to Melody valve-in-ring delivery. (A) The Melody device is crimped on the delivery balloon and advanced from the femoral vein, across the atrial septum, and positioned centrally in the partial annuloplasty ring. (B) Next, the Melody valve is deployed by balloon inflation. (C) Follow-up angiography reveals no significant mitral regurgitation, no left ventricular outflow tract obstruction, and (D) no aortic valve insufficiency. (LV = left ventricle.) The Annals of Thoracic Surgery 2012 93, 783-788DOI: (10.1016/j.athoracsur.2011.12.021) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Row A shows the intraoperative images after surgical mitral annuloplasty with 4 different types of annuloplasty ring. Row B shows necropsy pictures of the atrial side of the Melody valve-in-ring complex. Note that there is a complete circumferential seal formed between the Melody valve and the annular tissue, even in the absence of a complete ring (column 2). Row C shows the necropsy pictures of the ventricular side of the Melody valve-in-ring complex. In all cases, the mitral leaflet tissue “hugs” the outside of the Melody device. Although the Melody valve leaflets appear “gnarled” and “rolled,” in most cases the valves functioned well, with only 1 having hemodynamically significant mitral regurgitation. The Annals of Thoracic Surgery 2012 93, 783-788DOI: (10.1016/j.athoracsur.2011.12.021) Copyright © 2012 The Society of Thoracic Surgeons Terms and Conditions