Successful percutaneous paravalvular leak closure after mitral valve surgery

    Authors

    Keywords

    paravalvular leaks, percutaneous paravalvular closure device, mitral regurgitation, mitral annular calcification

    DOI

    https://doi.org/10.15836/ccar2025.231

    Full Text

    **Introduction**: Paravalvular leak (PVL) is a common problem after cardiac surgery, which independently increases morbidity and mortality (1). Based on the literature, percutaneous closure devices are a viable option in the treatment of the PVL, to defer repeat surgery and improve the overall prognosis (2). **Case report**: 66-year-old female previously underwent implantation of a mechanical mitral prosthesis (SJM Masters 33 mm) in October of 2024 for severe mitral regurgitation with secondary valvular cardiomyopathy. Her past medical history was significant for papillary thyroid carcinoma and lung carcinoid, treated with thoracic surgery and everolimus. Preoperative echocardiography revealed prolapse of both mitral cusps, with considerable calcification extending to the mitral anulus. Those findings were confirmed intraoperatively, and extensive mitral annular calcification (MAC) limited adequate prosthesis sealing, resulting in two considerable PVLs, superomedial and inferolateral (**Figure 1**). At first, it was decided to follow the patient without intervention as the early repeat surgery was deemed futile due to MAC. During follow-up, the patient exhibited laboratory results consistent with intravascular hemolysis, without significant anemia. Of note, there was a progressive dilatation of the left ventricle, with further deterioration of the systolic function that correlated with gradual clinical worsening. During follow-up, the Heart Team indicated that percutaneous closure was necessary, with heart CT for preprocedural planning. In May 2025, the patient was hospitalized for the closure of PVLs. Due to difficulty passing the catheter through the calcified lateral PVL, the leak was initially dilated with an Xtreme OTW balloon; subsequently, an Amplatzer Valvular plug (Abbott, 5x10 mm) was implanted. The medial leak was more easily passed, using the same closing device (**Figure 2**). Angiography after the procedure showed an optimal result. During follow-up, the patient is doing well, with only mild residual regurgitation. FIGURE 1. Paravalvular leaks shown on transesophageal echocardiography (marked with arrows). FIGURE 2. Paravalvular leak ocluder in position on transesophageal echocardiography. **Conclusion**: Proper preprocedural planning before PVL closure, utilizing multimodality imaging, is crucial for achieving optimal results. In an aging and polymorbid population where severe MAC is expected, PVL closure offers an alternative solution to addressing this challenge (3).

    Literature

    1. Calvert PA, Northridge DB, Malik IS, Shapiro L, Ludman P, Qureshi SA, et al. Percutaneous Device Closure of Paravalvular Leak: Combined Experience From the United Kingdom and Ireland. Circulation. 2016 September 27;134(13):934–44. https://doi.org/10.1161/CIRCULATIONAHA.116.022684
    2. Onorato EM, Muratori M, Smolka G, Malczewska M, Zorinas A, Zakarkaite D, et al. Midterm procedural and clinical outcomes of percutaneous paravalvular leak closure with the Occlutech Paravalvular Leak Device. EuroIntervention. 2020 February 20;15(14):1251–9. https://doi.org/10.4244/EIJ-D-19-00517
    3. Al-Hijji MA, El Sabbagh A, Guerrero ME, Rihal CS, Eleid MF. Paravalvular leak repair after balloon-expandable transcatheter mitral valve implantation in mitral annular calcification: Early experience and lessons learned. Catheter Cardiovasc Interv. 2019 November 1;94(5):764–72. https://doi.org/10.1002/ccd.28131
    Cardiologia Croatica
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    Successful percutaneous paravalvular leak closure after mitral valve surgery

    Extended Abstract
    Issue9-10
    Published
    Pages231-232
    PDF via DOIhttps://doi.org/10.15836/ccar2025.231
    paravalvular leaks
    percutaneous paravalvular closure device
    mitral regurgitation
    mitral annular calcification

    Authors

    Antonio Hanžek*ORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Vlatka Rešković LukšićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Joško BulumORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Zvonimir OstojićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Sandra Jakšić JurinjakORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Denis DošenORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Kristina Marić-BešićORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Ivica ŠafradinUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Marija BrestovacORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia
    Jadranka Šeparović HanževačkiORCIDUniversity Hospital Centre Zagreb, Zagreb, Croatia

    *Correspondence email: antoniohanzek0@gmail.com

    Full Text

    Introduction: Paravalvular leak (PVL) is a common problem after cardiac surgery, which independently increases morbidity and mortality (1). Based on the literature, percutaneous closure devices are a viable option in the treatment of the PVL, to defer repeat surgery and improve the overall prognosis (2).

    Case report: 66-year-old female previously underwent implantation of a mechanical mitral prosthesis (SJM Masters 33 mm) in October of 2024 for severe mitral regurgitation with secondary valvular cardiomyopathy. Her past medical history was significant for papillary thyroid carcinoma and lung carcinoid, treated with thoracic surgery and everolimus. Preoperative echocardiography revealed prolapse of both mitral cusps, with considerable calcification extending to the mitral anulus. Those findings were confirmed intraoperatively, and extensive mitral annular calcification (MAC) limited adequate prosthesis sealing, resulting in two considerable PVLs, superomedial and inferolateral (Figure 1). At first, it was decided to follow the patient without intervention as the early repeat surgery was deemed futile due to MAC. During follow-up, the patient exhibited laboratory results consistent with intravascular hemolysis, without significant anemia. Of note, there was a progressive dilatation of the left ventricle, with further deterioration of the systolic function that correlated with gradual clinical worsening. During follow-up, the Heart Team indicated that percutaneous closure was necessary, with heart CT for preprocedural planning. In May 2025, the patient was hospitalized for the closure of PVLs. Due to difficulty passing the catheter through the calcified lateral PVL, the leak was initially dilated with an Xtreme OTW balloon; subsequently, an Amplatzer Valvular plug (Abbott, 5x10 mm) was implanted. The medial leak was more easily passed, using the same closing device (Figure 2). Angiography after the procedure showed an optimal result. During follow-up, the patient is doing well, with only mild residual regurgitation.

    FIGURE 1. Paravalvular leaks shown on transesophageal echocardiography (marked with arrows).

    FIGURE 2. Paravalvular leak ocluder in position on transesophageal echocardiography.

    Conclusion: Proper preprocedural planning before PVL closure, utilizing multimodality imaging, is crucial for achieving optimal results. In an aging and polymorbid population where severe MAC is expected, PVL closure offers an alternative solution to addressing this challenge (3).

    Literature

    1. 1.
      Calvert PA, Northridge DB, Malik IS, Shapiro L, Ludman P, Qureshi SA, et al. Percutaneous Device Closure of Paravalvular Leak: Combined Experience From the United Kingdom and Ireland. Circulation. 2016 September 27;134(13):934–44.DOI
    2. 2.
      Onorato EM, Muratori M, Smolka G, Malczewska M, Zorinas A, Zakarkaite D, et al. Midterm procedural and clinical outcomes of percutaneous paravalvular leak closure with the Occlutech Paravalvular Leak Device. EuroIntervention. 2020 February 20;15(14):1251–9.DOI
    3. 3.
      Al-Hijji MA, El Sabbagh A, Guerrero ME, Rihal CS, Eleid MF. Paravalvular leak repair after balloon-expandable transcatheter mitral valve implantation in mitral annular calcification: Early experience and lessons learned. Catheter Cardiovasc Interv. 2019 November 1;94(5):764–72.DOI