Transcatheter Simultaneous Double-Transapical Access for Paravalvular Mitral Leak Closure Using the Occlutech PLD

Abstract: A 67-year-old patient with rheumatic heart valve disease had undergone two cardiac surgeries at the age of 30 years, then re-do with mitral valve replacement at 50 years. She presented with congestive heart failure and hemolytic anemia. Doppler echocardiography showed moderate-severe mitral regurgitation due to paravalvular mitral valve leak (PVML) and severe pulmonary hypertension. Transesophageal echocardiography demonstrated severe PVML secondary to a large 20 mm-long PVML defect. Due to comorbidities, the heart team deemed a third reoperation at very high surgical risk; therefore, the patient was considered most suitable for a transcatheter approach to PVML closure. Two Occlutech paravalvular leak devices were successfully delivered using a simultaneous double-transapical access with double-wire technique.

J INVASIVE CARDIOL 2016;28(7):E66-E68

Key words: paravalvular leak, transcatheter, transapical closure, mitral regurgitation

Case Presentation

A 67-year-old female with rheumatic valve disease underwent surgical mitral valve (MV) commissurotomy at the age of 30 years, then reoperation with MV replacement using a 25 mm mechanical MV (St. Jude Medical) 20 years later. The patient had been experiencing increased dyspnea and fatigue, and was finally admitted to hospital presenting with heart failure. Her blood work was compatible with hemolytic anemia (hemoglobin, 9.5 g/dL; indirect bilirubin, 1.5 mg/dL; lactic dehydrogenase, 792 mg/dL). Doppler echocardiography showed moderate-severe mitral regurgitation due to paravalvular mitral leak (PVML), and severe pulmonary hypertension (pulmonary artery systolic pressure, 85 mm Hg). Transesophageal echocardiography demonstrated severe PVML toward the posterolateral border of the mechanical MV (Figures 1A and 1B; Video 1). Three-dimensional transesophageal echocardiography confirmed a large PVML defect, with a 20 mm-long crescent-shaped disconnection (Figure 1C). The heart team considered a third reoperation to be at very high surgical risk; therefore, the patient was deemed most suitable for a transcatheter approach for PVML closure. 

The procedure was performed in a hybrid operating room using the transapical approach. The Occlutech Paravalvular Leak Device (PLD; Occlutech GmbH) was chosen (Figures 1D and 1E). Due to the PVML defect’s dimensions, a double-transapical access with a double-wire technique was planned. Two apical introducers (12 Fr and an 8 Fr short sheaths; St. Jude Medical) were inserted through the apical pursestring. A 12 mm rectangular-waist Occlutech PLD and a 5 mm square-twist Occlutech PLD were simultaneously delivered (Figures 1F-1I and Figure 2). The postoperative period was uneventful and the patient was discharged home 7 days after the procedure. At 8-month follow-up exam, she was in New York Heart Association class I, anemia was resolved and without parameters of hemolysis. Transesophageal echocardiography showed no PVML and pulmonary artery systolic pressure of 45 mm Hg.

Discussion

The present case demonstrates the successful management of a challenging anatomic feature in a patient with two prior MV surgeries with the implantation of two Occlutech PLDs. A double-transapical approach with simultaneous double-wire technique for PVML closure is a reasonable option when facing patients presenting with large PVML defects.

From the ¹Heart Team, Santa Maria Hospital, Bari, Italy; and ²Interventional Cardiology, London Health Sciences Centre, Western University. London, Ontario, Canada.

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.

Manuscript submitted March 13, 2016, provisional acceptance given March 20, 2016, final version accepted March 22, 2016.

Address for correspondence: Rodrigo Bagur, MD, PhD, FAHA, Division of Cardiology, London Health Sciences Centre, Assistant Clinical Academic Professor, Department of Medicine, Western University, 339 Windermere Rd, University Hospital, London, Ontario, Canada, N6A 5A5. Email: rodrigo.bagur@lhsc.on.ca