Author + information
- Ravinay Bhindi, MBBS, PhD, FRACP, FESC⁎,⁎ (, )
- Neil Ruparelia, MBBS, MRCP⁎,
- James Newton, MBChB, MRCP⁎,
- Neil Wilson, MBBS, FRCP† and
- Oliver J. Ormerod, DM, FRCP⁎
- ↵⁎Reprint requests and correspondence:
Dr. Ravinay Bhindi, Department of Cardiology, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom
A 69-year-old man presented with severe aortic regurgitation and ongoing hemolysis 14 years after the insertion of a 23-mm ATS Medical mechanical aortic valve. His symptoms were progressive, and on admission he was not able to walk farther than 100 meters on a flat surface and was generally fatigued as a consequence of his anemia. He was deemed a high-risk candidate for surgical repair in view of multiple comorbidities, including chronic renal failure, left ventricular dysfunction with resultant pulmonary edema, and atrial fibrillation. It was therefore decided to close his paravalvular leak percutaneously.
The procedure was performed under local anesthetic with intracardiac echocardiography guidance. Vascular access was achieved through a 9-F sheath inserted via the right femoral artery, and an aortogram confirmed a moderate-sized paravalvular leak (Fig. 1, Online Video 1). The paravalvular leak was crossed with a Terumo wire (Fig. 2) under fluoroscopic and echocardiographic guidance. The defect was then balloon-sized and was found to measure 5.3 mm (Online Video 2). An 8-mm Amplatzer muscular septal occluder device (AGA Medical Corporation, Plymouth, Minnesota) (Figs. 3 and 4)⇓⇓ was delivered via an 8-F El Gamal coronary guide catheter (Cordis, Miami Lakes, Florida) with a good final angiographic result (Fig. 5, Online Video 3). The patient made an uncomplicated recovery with improvement in both symptoms and hemolysis.
Symptomatic paraprosthetic leak after heart valve replacement is not an insignificant problem, occurring in approximately 1% to 5% of patients. Reoperation carries a higher risk compared with the initial surgery (1). Because this clinical presentation is more commonly observed in older patients, this risk is potentially further compounded by the presence of other comorbidities. Arising from this dilemma, percutaneous strategies used to treat other structural heart conditions have been modified and applied safely and successfully in this context.
This strategy is one that should be considered in appropriately selected cases, and with the development of equipment more specific for percutaneous paravalvular leak repair, is likely to become increasingly adopted.
For accompanying videos and their accompanying legends, please see the online version of this article.
Appendix Supplementary data
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.jcin.2008.04.012.
- American College of Cardiology Foundation