Paravalvular leakage (PVL) after mitral valve replacement surgery is a rare but serious complication occurring in approximately 5% of cases. Although many patients remain asymptomatic, those that develop heart failure, arrhythmias, endocarditis or severe hemolysis conventionally undergo surgical repair or replacement despite the higher morbidity and mortality with reoperation. Transcatheter techniques introduced in 1992 have proven to be a safe alternative to surgery, especially in high-risk patients with only a 1–2% risk of emergent surgery or death, with technical success rates ranging from 63 to 100% and clinical success rates ranging from 54 to 100% [1,2]. We report the first transapical PVL closure of a surgically constructed mitral annulus in a high-risk patient with an Amplatzer muscular ventricular septal defect (mVSD) closure device (AGA Medical Corporation; Plymouth, MN). A 56-year-oldmanhad an elective aorto-coronary bypass (LIMA-LAD, SVG-PDA, sequential SVG-OM1 and OM2) and mitral annuloplasty ring for severe mitral regurgitation in September 2006. In October 2006, he developed severe mitral PVL due to dehiscence of the annuloplasty ring with resultant hemolytic anemia. During surgery, the dehiscence of the annuloplasty ring was deemed to be unrepairable and a CarboMedics 33 mm mechanical valve with pledgetted sutures was placed in the mitral annulus. In November 2006, the patientwas readmitted for severe mitral PVL. During surgery, the valve was excised and due to insufficient tissue to hold the valve in the mitral annulus, a new annulus was surgically constructed and a CarboMedics 31 mm mechanical valve was implanted. In May 2007, he presented again with mitral PVL and hemolysis for which the patient underwent right thoracotomy, fibrillatory arrest and suture repair of two areas of mitral PVLs with pledgetted sutures. InNovember 2012, the patientwas admitted forheart failure and a three-dimensional TEE showed a severe mitral PVL due to large dehiscence from 9 to 12 o'clock in the left atrial view and no other leaks (Fig. 1). Since the mitral prosthesis was functioning well and the patient refused redo-surgery (logistic EuroSCORE—18.27%), we opted for the percutaneous PVL closure. The trans-septal approach was deemed to be