Transcatheter Closure of a Complex Paravalvular Leak Associated With a Large Ventricular Pseudoaneurysm

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00351. Epub December 30, 2024.

The successful transcatheter closure of paravalvular leaks (PVL) demands meticulous pre-procedural planning and a high level of technical expertise. Herein, we report our approach to managing a challenging case involving both a PVL and a large associated pseudoaneurysm (PA), ensuring complete exclusion of both (Video).

A 69-year-old man with multiple comorbidities and prior surgical mitral valve replacement presented with moderate-severe PVL causing heart failure symptoms and hemolysis. Preoperative transesophageal echocardiography (TEE) and multi-detector computed tomography (CT) revealed a PVL that extended from the left ventricle (LV) into a 4-cm PA that connected back into the left atrium (LA) at the 3 o’clock position (Figure 1).

CT-fluoroscopy fusion and TEE guidance was used to facilitate transeptal puncture and then traverse a hydrophilic wire across the PVL using a steerable sheath. This was snared in the LV to create an arterial-venous rail, and a shuttle sheath was advanced through the defects from the venous side. A 14-mm Amplatzer Vascular Plug II (Abbott) was then deployed, with 1 disc covering the LV entry site and the other secured at the LA entry site to effectively reduce the PVL and exclude the PA. There was no interaction with the bioprosthetic valve, and the patient was discharged with improved symptoms and resolution of his hemolysis.

In rare cases that PVL is associated with a PA, it is important to exclude flow from both the LA and LV side of the PA. This may require 2 separate vascular plugs (1 on each side), or 1 plug that is able to extend a proximal disc across the LA side and a distal disc over the LV side. Pre-procedural planning is key, and CT-fluoroscopy fusion may ease intraprocedural navigation.

Affiliations and Disclosures

Craig Basman, MD¹; Ryan Kaple, MD¹; Sung-Han Yoon, MD¹; Vladimir Jelnin, MD¹; Jessica Willert, MD²; Perry Wengrofsky, MD¹; George Stoupakis, MD¹

From the ¹Division of Cardiology, Department of Medicine; Hackensack University Medical Center; Hackensack, New Jersey; ²Department of Anesthesiology; Hackensack University Medical Center; Hackensack, New Jersey.

Disclosures: Dr Kaple is a consultant for Abbott and Edwards Lifesciences. The remaining authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and to the publication thereof.

Address for correspondence: Craig Basman, MD, 30 Prospect Avenue 1 Link, Hackensack, NJ 07601, USA. Email: craigbasman@gmail.com, craig.basman@hmhn.org; X: @craigbasman