Percutaneous Paravalvular Leakage Device Closure

- Operator : Young-Hak Kim

Percutaneous Paravalvular Leakage Device Closure

- Operator: Young-Hak Kim, MD

Case Presentation

A 54-year-old man presented with exertional dyspnea (New York Heart Association functional class III), recently aggravated for 6 months. He had undergone mitral valve replacement 13 years ago and was taking warfarin until now with optimal INR level. However, laboratory findings were consistent with hemolysis (hemoglobin level, 7.8 g/dL; Iron 32 ug/dL; TIBC 277 ug/dL; Ferritin 10.7 ng/mL; and lactate dehydrogenase level, 1,394 U/L) without other bleeding focus (Figure 1). As TTE showed a pin-point paravalvular leakge of prosthetic mitral valve (Figure 2), we planned to plug the hole.

Imaging Findings

On TEE, there was a 2mm sized tissue defect abbuting the lateral annulus of mechanical valve and the LAA annulus, and pin-point paravalvular leakage jet was observed through this hole ( Movie 1). But there was only a suspicious lesion of tissue defect at the appendage side of mitral valve on heart CT scan and the size hole cannot be measured (Figure 3, Yellow arrow).

Procedure

Under general anesthesia, 7Fr sheath was inserted through rt. femoral vein. Femoral vein sheath was exchanged for a Mullin sheath and dilator, which is advance over 0.032 inch guidewire into the superior vena cava. The guidewire is removed, and Brockenbrough needle was gently advanced to within a few milimeters of the tip of the dialtor, and needle is flushed and connected to a manufolder for continuous pressure monitoring. With fluoroscopic guidance, interatrial septum was punctured, and Mullin sheath was advanced into the left atrium. On the RAO-CRA 25°-25° view, the site of paravalvular leak was vertically placed with septal puncture line. Several attemps with 6Fr Judkins right 4.0 to engage the hole, finally we succeeded with 6Fr IMA catheter to engage the hole and angiography revealed a distorted, cylinder shaped hole, size measuring up to 6 x 8mm ( Movie 2). 0.035 inch J-tip terumo wire was used to cross the hole and for more stable support, we crossed the wire through aortic valve to descending aorta and exchanged into 0.035 inch terumo stiff wire using CXI catheter (Figure 4). And then for the device delivery, IMA catheter was exchanged into 6Fr Judkins right 4.0 and we advanced the Judkins catheter through the leakage hole and placed inside of LV (Figure 5). An Amplatzer Vascular Plug II (7mm*8mm) was then prepared and deployed across the paravalvular leakage site (Figure 6,Figure 7). Intraoperative transesophageal echocardiogram (TEE) revealed no residual leakage flow ( Movie 3). Additional fluoroscopic views also confirmed that the device was not impinging upon the mechanical valve leaflets. We are now expecting the hemolytic anemia to be corrected.