Journal of Invasive Cardiology

ABSTRACT: Aortic paravalvular leaks after aortic valve replacement surgery — though not uncommon as an incidental finding — may become clinically significant in up to 5% of patients. Open surgical correction by either direct suturing or patching of the defect or reoperative valve replacement is associated with significant morbidity and mortality. Relatively few case reports are available in the literature addressing percutaneous closure of aortic paravalvular leaks. We describe the novel use of intracardiac echocardiography and intravascular ultrasound to guide closure strategy selection and subsequent deployment of an Amplatzer duct occluder device. The patient experienced immediate subjective and hemodynamic improvement accompanied by rapid resolution of heart failure symptoms from New York Heart Association (NYHA) class IV to NYHA class II. This marked clinical improvement has been sustained at 40 months to date and 4-month follow-up echocardiography confirmed complete resolution of aortic regurgitation as the mechanism behind this improvement.

Prosthetic paravalvular leaks (PVL) are common, occurring after 2–17% of prosthetic valve replacements.^1,2 While small PVL may cause hemolysis, they are usually well tolerated. Larger PVL, however, may cause heart failure due to severe regurgitation. While the preferred option is surgical, reoperation is associated with significant morbidity and mortality.^3,4,8–11 Percutaneous closure of the PVL is sometimes undertaken in patients with significant co-morbidities using any of a variety of devices originally intended for other purposes. Such “off-label” uses of these devices may result in under-reporting in the literature.^13–27 Webb et al have reported one of the larger “series” of PVL managed percutaneously; however, only one of those cases was an aortic PVL.²³ Here we describe the successful closure of an aortic PVL with an Amplatzer Duct Occluder (AGA Medical Corporation, Plymouth, Minnesota), using both intravascular ultrasound (IVUS) and intracardiac echocardiogram (ICE) for imaging of the PVL tract in order to inform specific occluder device selection and, in the case of ICE, to monitor progress and acute success of the procedure.