Novel Repair of a Paravalvular Leak in the Mitral Annulus
Poster #: 065
Session/Time: B
Author:
Hemish McAvelli Philip, BS
Mentor:
Matthew Summers, MD
Research Type: Case Report
Abstract
INTRODUCTION:
Paravalvular leaks (PVL) in prosthetic heart valves are relatively common, occurring in 7-17% of artificial valves [1]. However, non-transvalvular regurgitation in native mitral valves is extremely rare. The mitral annulus, a fibrous ring, resists tearing or deformation under normal conditions. Compared to the aortic annulus, it experiences less hemodynamic stress, lowering the likelihood of leaks [2].
CASE INFORMATION:
A 63-year-old woman presented with shortness of breath, fatigue, and lower extremity edema. Her history included moderate posterior Mitral Annular Calcification (MAC), chronic diastolic heart failure with preserved EF (61%), and coronary artery disease with severe RCA stenosis (80%). Transesophageal echocardiography (TEE) demonstrated moderate-severe mitral regurgitation, with an eccentric posterolateral jet and anterior-medial course (Figure 1). Three-dimensional TEE with Doppler provided additional visualization (Figures 2, 3). She was diagnosed with a PVL in the native mitral annulus. Due to high surgical risk, the defect was treated percutaneously with an Amplatzer AVP4 plug. The procedure was uncomplicated. Intra-procedural TEE confirmed a well-seated device. She was discharged on hospital day 2 with transthoracic echocardiography showing no significant residual regurgitation.
DISCUSSION:
Mitral PVLs are often detected incidentally but can cause heart failure or hemolytic anemia. In this case, symptoms were from volume overload rather than hemolysis. Since her anemia was mild and labs unremarkable, we attributed her presentation to mitral insufficiency. Surgical repair was avoided due to comorbidities. While surgery remains the gold standard, percutaneous closure is increasingly favored for its minimally invasive nature and comparable efficacy [3]. We utilized an Agilis steerable sheath to cross the interatrial septum under 3D imaging guidance. Initial wiring was achieved with a 0.035" Glidewire, then exchanged for a 0.014" Sion Black coronary wire. This served as a rail for a CatRx coronary aspiration catheter. Once position was confirmed, an Amplatzer AVP4 was deployed while maintaining LV wire access. This wire-guided approach allowed stable access and precise deployment. Early recognition of PVLs is crucial, as untreated cases may lead to progressive heart failure or hemolytic anemia [4]. Current ACC/AHA guidelines recommend periodic transthoracic echocardiography after valve replacement, with TEE reserved for unexplained symptoms, hemolysis, or suspected dysfunction [5]. Percutaneous closure is a safe, effective alternative to redo surgery for symptomatic PVLs, especially in high-risk patients.
Paravalvular leaks (PVL) in prosthetic heart valves are relatively common, occurring in 7-17% of artificial valves [1]. However, non-transvalvular regurgitation in native mitral valves is extremely rare. The mitral annulus, a fibrous ring, resists tearing or deformation under normal conditions. Compared to the aortic annulus, it experiences less hemodynamic stress, lowering the likelihood of leaks [2].
CASE INFORMATION:
A 63-year-old woman presented with shortness of breath, fatigue, and lower extremity edema. Her history included moderate posterior Mitral Annular Calcification (MAC), chronic diastolic heart failure with preserved EF (61%), and coronary artery disease with severe RCA stenosis (80%). Transesophageal echocardiography (TEE) demonstrated moderate-severe mitral regurgitation, with an eccentric posterolateral jet and anterior-medial course (Figure 1). Three-dimensional TEE with Doppler provided additional visualization (Figures 2, 3). She was diagnosed with a PVL in the native mitral annulus. Due to high surgical risk, the defect was treated percutaneously with an Amplatzer AVP4 plug. The procedure was uncomplicated. Intra-procedural TEE confirmed a well-seated device. She was discharged on hospital day 2 with transthoracic echocardiography showing no significant residual regurgitation.
DISCUSSION:
Mitral PVLs are often detected incidentally but can cause heart failure or hemolytic anemia. In this case, symptoms were from volume overload rather than hemolysis. Since her anemia was mild and labs unremarkable, we attributed her presentation to mitral insufficiency. Surgical repair was avoided due to comorbidities. While surgery remains the gold standard, percutaneous closure is increasingly favored for its minimally invasive nature and comparable efficacy [3]. We utilized an Agilis steerable sheath to cross the interatrial septum under 3D imaging guidance. Initial wiring was achieved with a 0.035" Glidewire, then exchanged for a 0.014" Sion Black coronary wire. This served as a rail for a CatRx coronary aspiration catheter. Once position was confirmed, an Amplatzer AVP4 was deployed while maintaining LV wire access. This wire-guided approach allowed stable access and precise deployment. Early recognition of PVLs is crucial, as untreated cases may lead to progressive heart failure or hemolytic anemia [4]. Current ACC/AHA guidelines recommend periodic transthoracic echocardiography after valve replacement, with TEE reserved for unexplained symptoms, hemolysis, or suspected dysfunction [5]. Percutaneous closure is a safe, effective alternative to redo surgery for symptomatic PVLs, especially in high-risk patients.