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Failed closure of paravalvular leak with an amplatzer occluder device after mitral valve replacement.

A 64-yr-old man presented for surgical intervention of a persistent paravalvular mitral valve (MV) regurgitant leak. The patient’s medical history included aortic valve (AV) and MV replacement surgery with mechanical prosthesis 2 yr before the current presentation. His postoperative course had been complicated by anemia and gastrointestinal bleeding, requiring multiple red blood cell transfusions. Further evaluation revealed a gastric arteriovenous malformation and chronic renal insufficiency. In addition, the patient was found to have a MV paravalvular leak associated with hemolytic anemia. Due to the patient’s co-morbidities, the paravalvular leak was closed using a percutaneous catheter approach with an Amplatzer® muscular ventricular septal defect occluder device (AGA Medical Corporation, Golden Valley, MN). Several months after closure, the patient reported symptoms of shortness of breath and was found to have profound anemia, predominantly hemolytic in origin (decreased haptoglobin, elevated lactate dehydrogenase). A transthoracic echocardiogram was indeterminant due to suboptimal image quality from the patient’s profound obesity. A subsequent transesophageal echocardiogram (TEE) revealed the presence of the occluder device and a moderately-severe MV paravalvular regurgitant jet; the mechanical AV prosthesis was intact. Intraoperative TEE confirmed preoperative findings of mechanical bi-leaflet MV prosthesis, which was wellseated in the valve annulus without accompanied “rocking” motion. A moderately-severe paravalvular MV leak was noticed around the Amplatzer device. The device itself was malpositioned and shifted from the proper horizontal and parallel position of both occluder disks with the valvular annular plane to an angle directed improperly toward the left atrium (Figs. 1 and 2 and Video clips 1 and 2; please see video clips available at www.anesthesia-analgesia.org). The patient underwent an uneventful reoperation for replacement of both the AV and MV with bioprosthesis (Video clip 3; please see video clips available at www.anesthesia-analgesia.org). The decision to replace the AV mechanical prosthesis was made preoperatively to avoid potential postoperative gastrointestinal bleeding episodes secondary to anticoagulation. The incidence of paravalvular regurgitation after primary MV replacement with mechanical or bioprosthetic valves is reported to be 12.5%. The paravalvular regurgitation developing in the nonimmediate postoperative period may be secondary to suture dehiscence or as a consequence of valvular endocarditis. In comparison to sometimes technically difficult transthoracic echocardiography, TEE offers improved sensitivity for detection of paravalvular regurgitant jets. Reported indications for use of percutaneous techniques as a treatment option for patients with paravalvular leaks include patients with severe heart failure, transfusion-dependent hemolysis and patients requiring prolonged postoperative ventilatory support. Percutaneous techniques with the use of the Amplatzer occluder device have been described in the literature for closure of paravalvular regurgitant jets in patients unfit for surgery because of the high procedural risk. Cortes et al. described a case series documenting successful implantation of the Amplatzer device with minimal associated patient morbidity. Immediate postdeployment complications may include interference of normal prosthetic valve leaflet motion, i.e., preventing prosthesis opening, thrombus formation as well as residual atrial septal defect after the transseptal approach. Device dislodgment has been reported as a late complication of the procedure. This article has supplementary material on the Web site: www.anesthesia-analgesia.org.