First Report of Supra-Annular Atrially Placed Bioprosthetic Mitral Valve Leak Closure Through Percutaneous Approach

J INVASIVE CARDIOL 2019;31(10):E303.

Key words: paravalvular leak closure

An 81-year-old man underwent mitral valve replacement using a 29 mm pericardial valve (Labcor) in 2015 for severe calcific mitral stenosis. The surgeon reported at the time that the prosthesis had to be sutured in a supra-annular position into the left atrial wall because of a heavily calcified mitral annulus (Video 1). The patient had been hospitalized repeatedly since with pulmonary edema. Transthoracic echocardiography (TTE) showed a normal left ventricular ejection fraction (LVEF), peak/mean pressure gradient of 27/7 mm Hg with high initial velocity (>240 cm/s), and pressure half time of 68 ms, suggestive of significant mitral regurgitation. Transesophageal echocardiography (TEE) showed two severe eccentric paravalvular regurgitation jets in posteromedial and posterolateral locations (Videos 2 and 3). Review of the operative report showed that the mitral leaflets were removed with some decalcification of the mitral annulus and 2-0 Tevdek pledged interrupted sutures (Teleflex Medical) were positioned supra-annularly in the left atrial tissue at the level of the left atrial appendage. Given the risk and questionable success of a reoperation, the decision was made to attempt percutaneous paravalvular leak (PVL) closure. 

The procedure was performed under TEE guidance using an 8 Fr upgraded to 14 Fr catheter via a right femoral vein approach. The PVLs were located at the posterolateral and posteromedial aspects of the bioprosthetic valve, which is radiolucent on angiography. Transseptal access was obtained and a steerable sheath (Oscor) was advanced to the left atrium. A Terumo wire was used to cross the posterolateral leak and exchanged to a Safari wire (Boston Scientific) through a JR 4.0 x 5 Fr wire (Videos 4 and 5). The 9 Fr delivery system of the 14 x 6 mm Occlutech occluder device was advanced to the leak and deployed (Videos 6 and 7) with 70%-80% reduction in the severity of the PVL. The posteromedial leak was then crossed with an exchange wire (Terumo) and snared from the left femoral artery for better support and creation of an arteriovenous rail (Video 8). A 7 Fr shuttle sheath was advanced to the leak and a 14 x 5 mm Amplatzer Vascular Plug 3 (Abbott Vascular) was deployed (Figure 1) with complete resolution of the leak (Video 9). TEE showed significant decrease in both PVLs (Video 10) and resolution of systolic flow reversal in the pulmonary veins. The patient is now 5 months post leak closure with complete resolution of symptoms, no heart failure readmissions, and NYHA class I symptoms.

This is the first described case of supra-annularly placed mitral PVL closure in the literature.

View the Supplemental Video here.

From the American University of Beirut Medical Center, Division of Cardiology, Beirut, Lebanon.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 5, 2019.

Address for correspondence: Fadi Sawaya, MD, Assistant Professor of Medicine, Interventional Cardiologist, Director Structural Heart Program, American University of Beirut Medical Center, Cairo Street, Beirut, Lebanon. Email: fjsawaya@gmail.com