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Failed Closure of Paravalvular Leak with an Amplatzer® Occluder Device After Mitral Valve Replacement

Alfirevic, Andrej MD; Koch, Colleen Gorman MD, MS, FACC

doi: 10.1213/ane.0b013e31818ef060
Cardiovascular Anesthesiology: Echo Rounds
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From the Department of Cardiothoracic Anesthesia, Cleveland Clinic, Cleveland, Ohio.

This article has supplementary material on the Web

Accepted for publication July 28, 2008.

We have had full access to all data in this report and take responsibility for the integrity and accuracy of this report. This report has neither been previously published, nor submitted elsewhere. There are no conflicts of interest for any of the authors, nor are there outside funding sources to disclose. Conditions for publication forms signed by each author for authorship responsibility, criteria, contributions, and financial disclosure will be submitted via mail.

Address correspondence and reprint requests to Andrej Alfirevic, MD, 9500 Euclid Av, Cleveland, OH 44195. Address e-mail to

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 well-seated 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 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 The decision to replace the AV mechanical prosthesis was made preoperatively to avoid potential postoperative gastrointestinal bleeding episodes secondary to anticoagulation.

Figure 1

Figure 1

Figure 2

Figure 2

The incidence of paravalvular regurgitation after primary MV replacement with mechanical or bioprosthetic valves is reported to be 12.5%.1 The paravalvular regurgitation developing in the nonimmediate postoperative period may be secondary to suture dehiscence or as a consequence of valvular endocarditis.1 In comparison to sometimes technically difficult transthoracic echocardiography, TEE offers improved sensitivity for detection of paravalvular regurgitant jets.2

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.3 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.3,4 Cortes et al.4 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.3,4 Device dislodgment has been reported as a late complication of the procedure.5

The ability of TEE to accurately locate the region of dehiscence likely contributes to the success of the percutaneous device repair for MV paravalvular leaks.4 In addition, TEE examination provides a measure of procedural success by providing for initial and long-term assessment of the valvular function once the occluder device has been placed and regurgitation leak sealed.4

Echocardiographic characteristics of MV paravalvular regurgitation jets include a turbulent jet, as imaged by color flow Doppler imaging, varying in magnitude depending on the size of the defect and often eccentric in direction towards the left atrial wall displaced away from the valvular annulus. Regions of proximal flow acceleration may be noted with color flow Doppler on the left ventricular side of the valve. In addition to the qualitative and semi-quantitative assessment of the MV paravalvular regurgitation, potential obstruction of the MV inflow has to be excluded. Obstruction to MV inflow may be noted by abnormal MV prosthesis leaflet motion as detected with two-dimensional echocardiography. Intraoperative continuous-wave Doppler imaging may detect an increase in the pressure gradient across the prosthesis with the differential diagnosis, including occluder device displacement, obstructed prosthetic leaflet opening and thrombus formation.3,4 Procedural success in terms of proper placement should demonstrate the occluder device’s two disks visualized, from several midesophageal TEE views, well-seated within the defect providing an optimal seal.5 (Fig. 2) Due to the metallic properties (Nitinol wire mesh) of disks, the caudal disk may be acoustically shadowed by the cephalad disk when evaluated from the midesophageal TEE views. Therefore, for thorough two-dimensional imaging of disks location, transgastric TEE views, such as two-chamber view, may also be helpful.

In conclusion, TEE is an important modality for diagnosing paravalvular leaks and is an integral tool to guide definitive therapy treatment with either percutaneous catheter techniques or open heart procedures.

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