Clinical Images

Complex Plug-Prosthesis Interaction During Percutaneous Closure of Mitral Paravalvular Leak: The Butterfly Effect

Francesco Melillo, MD1; Daniele Cocco, MD1; Stefano Stella, MD1; Giacomo Ingallina, MD1; Luigi Pannone, MD1; Barbara Bellini, MD2; Vittorio Romano, RT2; Luca Ferri, MD2; Matteo Montorfano, MD2; Eustachio Agricola, MD1

Francesco Melillo, MD1; Daniele Cocco, MD1; Stefano Stella, MD1; Giacomo Ingallina, MD1; Luigi Pannone, MD1; Barbara Bellini, MD2; Vittorio Romano, RT2; Luca Ferri, MD2; Matteo Montorfano, MD2; Eustachio Agricola, MD1

J INVASIVE CARDIOL 2020;32(7):E196-E197.

Key words: fusion imaging, mitral valve, paravalvular leak, transcatheter


A 57-year-old woman presented with heart failure and hemolytic anemia requiring blood transfusions. Six months prior, she underwent a surgical replacement of the aortic and mitral valves with two mechanical prostheses for severe aortic and mitral stenosis. Because of the calcium burden in both annuluses, undersized prostheses were implanted, leading to the presence of two moderate mitral paravalvular leaks (PVLs). Transesophageal echocardiography (TEE) confirmed the presence of a large anterolateral PVL and a small medial PVL (Figure 1A). Three-dimensional (3D) vena contracta area was 0.32 cm2 and 0.2 cm2, associated with reverse flow in the pulmonary veins. Given the high surgical risk, percutaneous closure with 3D-TEE and fluoroscopy fusion imaging guidance was planned. After transseptal puncture, the medial leak was effectively closed with two 6 mm Amplatzer Vascular Plug II devices (Abbott Vascular) (Figures 1B and 1C). The lateral leak was then engaged (Figure 1D; Video 1) and a 10 mm Amplatzer Vascular Plug II was advanced, causing an intermittent interference with both the lateral and medial disks of the prosthesis; the direct interference with the lateral disk caused an intermittent blockage in the closing position (leading to moderate stenosis, medium gradient 7 mm Hg) and in the opening position (leading to a severe intraprosthetic regurgitation) (Figure 1E; Video 2). The medial disk was intermittently blocked in the closing position (Figure 1F; Video 3) due to the bulky effect of the devices passing through the lateral leak, medially pulling and displacing the prosthesis. To avoid this interference, the plug was released with a marked atrial protrusion, but soon after the device embolized in the left atrium (Figure 1G; Video 4). The plug was then captured and an Amplatzer Vascular Plug III (10-5 mm) was placed in the lateral position. After removing the wires, the disk mobility was restored and the residual mild paravalvular regurgitation appeared further reduced (Figure 1H). The postoperative course was uneventful. At predischarge transthoracic echocardiography, the residual PVL was trivial with no more laboratory signs of hemolysis.

The percutaneous closure is a less invasive alternative to surgical PVL closure. However, it is a technically demanding procedure that requires both careful preprocedural planning and intraprocedural guidance. 3D-TEE fluoroscopic-fusion imaging is extremely helpful for intraprocedural monitoring. The knowledge of possible complications is warranted for achieving an optimal result. Recent series showed similar 1-year outcome compared with surgery, but few data are available about intraprocedural issues, especially those related to plug-prosthesis interference. In only 1 patient, late infective endocarditis with device embolization and new leaflet interference was reported. Here, we clearly show how interaction between imaging experts and interventionists allowed us to overcome the challenge of plug-prosthesis interaction in a complex procedure.

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From the 1Noninvasive Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy; 2Interventional Cardiology Unit, Cardiology and Cardiothoracic Surgery Department, San Raffaele University Hospital, Milan, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted November 14, 2019.

Address for correspondence: Dr. Francesco Melillo, San Raffaele University Hospital, Via Olgettina 60, 20132 Milan, Italy. Email: melillo.francesco@hsr.it

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