Percutaneous Closure of Mitral Paravalvular Leaks Generating Refractory Heart Failure in the Immediate Postoperative Period

J INVASIVE CARDIOL 2019;31(8):E259-E260.

Key words: heart failure, paravalvular leak, vascular plug

Paravalvular leaks (PVLs) after surgical valve replacement (SVR) are common. Surgical reoperation is associated with a high morbidity rate. Percutaneous closure in the immediate postsurgical period is not advised due to the potential risk of disruption of the valve suture. We present two patients with refractory heart failure (HF) due to mitral PVL in whom percutaneous PVL closure was performed in the immediate postoperative period.

Patient #1. A 69-year-old male with history of aortic SVR and coronary artery bypass graft had endocarditis, and therefore underwent surgical implantation of a biologic mitral prosthesis and a mechanical aortic prosthesis. The immediate course was complicated with refractory HF secondary to severe mitral regurgitation (MR) generated by a posterior PVL. The heart team decided on percutaneous closure, which was performed on day 8 post surgery. The PVL was crossed with a straight wire that was captured at the left atrium, establishing the arteriovenous loop, with release of a 10 x 3 mm Amplatzer Vascular Plug III (VPIII; Abbott Vascular), maintaining the wire of the circuit (Figure 1A). A residual jet was visualized (Figure 1B and Video 1), so a second 10 x 3 mm VPIII was advanced parallel to the previous device (Figure 1C) and released with a good result (Figure 1D and Video 2).

Patient #2. A 61-year-old male with mitral and aortic mechanical prostheses presented with acute mitral thrombosis (Video 3) treated with urgent mitral ATS prosthesis implantation (ATS Medical). The immediate course was complicated with persistent HF due to an anterolateral PVL generating severe MR (Figure 2A and Video 4) that was percutaneously treated with implantation of a 12 x 5 mm VPIII on day 5 post surgery (Figures 2B and 2D; Video 5).

Both patients progressed favorably and were discharged in the following days. From a technical point of view, both defects were large and presented straight borders that possibly improved the device apposition. Percutaneous closure of PVLs in the immediate postsurgical period may be safe and effective in selected patients with refractory HF.

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From the Departments of ¹Interventional Cardiology; ²Cardiac Image Unit; ³Cardiac Surgery; and ⁴Anesthesiology, HM Hospitales-Hospital Universitario HM Montepríncipe, Madrid, Spain.

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 January 10, 2019.

Address for correspondence: Leire Unzué MD, PhD, Unidad de Hemodinámica y Cardiología Intervencionista, HM Hospitales-Hospital Universitario HM Montepríncipe, Avenida de Montepríncipe, 25, 28668 Boadilla del Monte, Madrid, España. Email: leireunzue@yahoo.es