Paravalvular leak (PVL) which described as abnormal retrograde flow between sewing ring and native valve annulus is a known complication of valvular replacement [1,2]. Depending on its size and location, PVL may cause heart failure, hemolysis or both. Newer percutaneous techniques have been developed for treatment of PVL [3]. Here we present a case in which a transapical PVL closure have been successfully performed.

A 67 year old man, who had mitral and aortic valve replacement surgery 10 years ago admitted to our outpatient clinic with signs and symptoms of heart failure. He had three valvular operations which the two of them had been performed for treatment of paravalvular leak. He had fatique, exertional dyspnea and signs indicating low output state. He had performed 100 meters in 6-minute walk test on admission. His pro-BNP was 3150 pg/ml. He had signs indicating hemolysis. His hemoglobin concentration was 9.1 g/dL and lactate dehydrogenase level was 321 IU/L. On transthorasic echocardiography (TTE) an anteromedially located PVL was observed. The paravalvular leak was located anteromedially, at 2 to 4 o’clock position by 3D transesophegeal echocardiography (Figure 1). Considering his previous operations which substantially increase his risk for a redo surgery, a percutaneous treatment for PVL had planned. As he had both aortic and mitral valvular prothesis, transapical approach (TA) for PVL closure was chosen.

Figure 1: Mitral paravalvular leak before the procedure (image with 3D-TEE).

Upon decision to perform PVL via TA approach computer tomography angiography (CTA) performed to determine the appropriate access site. Left anterior descending artery was identified and a proper access site was determined 13 mm lateral to LAD, 12.9 mm inferior to second intercostal space (Figure 2). The proper angle was calculated from the access site to mitral PVL by CTA (Figure 3).

Figure 2: Left ventricular access site determination with computer tomography angiography (CTA).

Figure 3: The angle between left ventricular access site and mitral paravalvular leak.

The skin above the pre-determined access site was marked. Before the puncture, a coronary angiogram was performed to determine exact localisation of LAD in order to prevent possible damage. A seldinger needle of 22 g size was used to puncture of LV. Upon receiving pulsatile flow at the tip, radiocontrast was injected through needle to ensure the position in LV. The sheath of 7F size and 25 mm length (Terumo, Japan) was introduced. After the access site was secured, heparin was administered. A 0.035’’ 260 mm length Radiofocus angled Terumo guidewire (Terumo, Japan) was advanced through anteromedially located PVL and the position of the wire confirmed in left atrium (Figure 4). The introducer sheath then advanced and positioned in the left atrium over the wire. The two Amplatzer Vascular Plug III (AVP III, St.Jude Medical) of 3 mm width and 14 mm length (AVP III, 9 AVP -143) were advanced and placed through mitral PVL sequentially via 3D TEE and flouroscopy guidance (Figure 5). The PVL diminished to minimal and no interaction with valvular prosthesis was observed (Figure 6). After successfully closing the PVL, the exit through LV apex was closed with Amplatzer Duct Occluder II (ADO II, St. Jude Medical). The ADO II (ADO II, 9PDA-004) was advanced through sheath and the system pulled back until it resides on LV apex. Then the system completely pulled back and the ADO II left in LV puncture site (Figure 7). No pericardial effusion was observed and the patient discharged on third post-operative day uneventfully.

Figure 4: Terumo guidewire advanced through PVL.

Figure 5: Fluoroscopic image of catheter and Amplatzer Vascular Plug III advanced through PVL.

Figure 6: 3D TEE image of Two AVP III devices deployed.

Figure 7: Left ventricular puncture site successfully closed with Amplatzer Duct Occluder.

The reported incidence of PVLs range between 2% to 10% for aortic position and 7% to 17% for mitral position [1,2]. As PVL surgery has considerable risk for morbidity and mortality, a less invasive alternative have been developed. Hourihan performed the first reported transcatheter closure of PVL in 1992 with double umbrella device and since then the technique is considerably developed [3]. Percutaneous PVL closure has been shown to be safe and effective treatment in different series [4,5-7].

There are number of approaches for PVL closure including transseptal (TS) access, apical left ventricular (LV) access and retrograde femoral access. The choice of approach is mainly affected by the valve involved, location of PVL and local expertise. In the case presented, presence of aortic valve prothesis and anteromedial position of PVL led us to choose TA access. TA access can be provided by direct puncture or open surgical LV apical access via left anterolateral mini thoracotomy [8,9]. There is no direct comparison of open surgical and percutaneous TA access to date, so the decision is mainly dependent on experience of the operator. We choose to perform direct LV puncture as it is less invasive and traumatic, especially in this patient group whom require anticoagulation treatment. The LV puncture was confirmed with radiocontrast injection through the needle. A left ventriculogram could be used for patients who do not have aortic valvular prosthesis. In our case, the presence of aortic prothesis disregards such an option.

There is no specifically designed device or delivery system for PVL closure. We have chosen to use Amplatzer vascular plug III (AVP III, St. Jude Medical) which has an oblong shape and relatively small retention rims. The shape of AVP III provide advantage for closure of crescentic PVLs. It’s feasibility and safety have been shown in clinical studies of transapical PVL closure [10,11].

Following percutaneous TA puncture, use of closure devices is recommended if the sheats used are larger than 5F [12]. For smaller sheats, the access site is generally occluded by LV myocardial motion. In accordance with previous reports we closed the puncture site with an Amplatz Duct Occluder II (ADO II,St. Jude Medical) as we had used a 7F sheat. Meticulous pre-procedure planning and safe exit from LV via using an occluder device enabled us to omit major complications of LV apical puncture such as laceration of coronary, pleural or intercostal vessels during access or hemothorax caused by bleeding from LV puncture site [12,13].

TA approach for percutaneous mitral PVL closure is associated with favorable outcomes and acceptable morbidity in patients with high surgical risk [8,9]. It also decreases procedure and fluoroscopy times, provides opportunity to directly cross mitral PVL defects. Although there are number of complications associated with procedure, careful patient selection and pre-procedural planning will improve the results.