Successful transcatheter bioprosthetic heart valve paravalvular leak closure: the role of 3-dimensional transesophageal echocardiography.

Dear Editor, Case Report Patient This 60-year-old male had rheumatic mitral valve stenosis treated with open mitral valvotomy in 1982, percutaneous transmitral commissurotomy in 2008 and mitral valve replacement (29 mm EPICTM bioprosthetic mitral valve) plus tricuspid valve ring annuloplasty in 2009. He remained dyspnoeic after surgery. On auscultation, the pulmonary component of the second heart sound was loud with no obvious mitral regurgitant murmur. Two separate transthoracic echocardiograms failed to demonstrate prosthetic valve dysfunction. However, transmitral gradient was disproportionately high for the prosthetic valve type (6 to 12 mm Hg, depending on heart rate) with exaggerated ventricular interdependence. Cardiac catheterisation showed severe pulmonary venous hypertension (wedge pressure 28 mmHg , mean pulmonary artery pressure 49 mmHg). Subsequently, transesophageal echocardiography revealed severe, eccentric mitral paravalvular regurgitation (PVR) arising from a 4 mm dehiscence at the lateral aspect of the mitral annulus (Fig. 1A). Procedure Under general anaesthesia, a trans-septal puncture was performed to permit left atrial access. Three-dimensional transesophageal echocardiogram (3DTEE) showed a cresentic defect measuring 20 x 6 mm (1.1 cm2 on planimetry) (Fig. 1B). An 8.5 Fr Agilis NXTTM Medium Curve Steerable Sheath was advanced across the septum with its tip positioned near the defect (Fig. 1C). A 6Fr MPA2 coronary guide catheter was telescoped within the Agilis sheath, following which, a 260 cm stiff Terumo angled glidewire® was used to cross the defect, guided by 3DTEE (Fig. 1D and 1E). The coronary guide was then advanced towards the LV apex over the wire and the Agilis sheath rail-roaded over the guide across the defect. The wire and coronary guide were then removed. A 16 mm Amplatzer® Vascular Plug II was advanced through the Agilis sheath and sandwiched the defect effectively. 3DTEE confi rmed device stability and showed reduction in severity of PVR (mild-moderate) (Fig. 1F).