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J Thorac Cardiovasc Surg 2003;126:879-880
© 2003 The American Association for Thoracic Surgery

Brief communications

Management of mitral paravalvular leak: Therapy or misadventure?

^a Department Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India

Received for publication March 7, 2002; accepted for publication March 25, 2003.

^* Address for reprints: Dr A. Sampath Kumar, Professor, Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi -110029, India
asampath_kumar{at}hotmail.com

Devagourou, Sampath Kumar, Hussain

After mitral valve replacement, surgical closure of paravalvular leak is usually advised in severely symptomatic patients and in those requiring blood transfusion for persistent hemolysis. We present a case of persistent paravalvular leak after atrial septal defect device closure following mitral valve replacement (MVR).

Clinical summary

A 37-year-old man with severe rheumatic mitral stenosis underwent open mitral commissurotomy on September 3, 1997. Severe mitral restenosis and increasing dyspnea developed, progressing to New York Heart Association class IV, for which he required reoperation. MVR was performed with a 3M Starr-Edwards prosthesis (Edwards Lifesciences, Irvine, Calif) through heart port access on June 26, 1999. One year after the operation, he had progressively increasing dyspnea on exertion, again with pedal edema and yellow discoloration of the urine and eyes. Severe mitral paravalvular leak was diagnosed. He underwent transcatheter closure of the paravalvular leak with an Amplatzer device (AGA Medical Corporation, Golden Valley, Minn) on December 4, 2001, via the right femoral vein. All the above procedures were performed at another institution.

He came to our institution with symptoms of progressively increasing dyspnea on exertion and jaundice. General physical examination revealed pallor, jaundice, pedal edema, and hepatomegaly. Cardiovascular examination revealed a loud second heart sound in the pulmonic area and a pansystolic murmur in the mitral area, a clinical picture of severe congestive heart failure. The hemogram and peripheral blood smear were consistent with hemolytic anemia. The echocardiogram revealed the mitral valve prosthesis and severe paravalvular leak with the device in situ. Cardiac catheterization and angiography (Figure 1) revealed paravalvular leak with severe mitral regurgitation and severe pulmonary venous and pulmonary arterial hypertension.

View larger version (179K): [in this window] [in a new window]   Figure 1. Left ventricular angiographic picture showing the Starr-Edwards prosthesis, the Amplatzer device, and mitral regurgitation.

View larger version (135K): [in this window] [in a new window]   Figure 2. A, The prosthetic valve and device in situ. B, The excised prosthetic valve and device.

The management of paravalvular leak after valve replacement has been operative repair. A search of the English literature (MEDLINE, PUBMED) revealed a previous report of transcatheter device closure. Transcatheter umbrella device closure of valvular and paravalvular leaks was described by Hourihan and colleagues¹ in 1992. They reported closure with a Rashkind double-umbrella device in 8 patients with high operative risk. Four patients had a paravalvular leak around a prosthetic aortic valve and 4 other patients had a valvular leak: 1 patient with a regurgitant native aortic valve after a Stansel procedure and 3 patients with a regurgitant porcine valve in a left ventricular apex—descending aorta conduit.

We did not find reports of transcatheter device closure of a mitral paravalvular leak during our search. Our patient was young and in relatively good health when he presented to us. We planned surgery because surgical fixation is the definitive management of this condition, although he had been advised reclosure with a device for the persistent paravalvular leak at the previous institution.

We believe paravalvular leak after valve replacement is best corrected by prompt reoperation. Attempts to close the eccentric, sometimes large defects with devices are associated with many more complications. In addition, they are generally not successful in correcting the paravalvular leak. Although it may be a technical achievement in placing such a device, especially in the mitral paravalvular area, it is best to restrict such a procedure to patients in whom contraindications exist for surgery. The effort, expense, and expert maneuvering of a device in this situation are in our opinion a futile exercise.

References

1. Hourihan M, Perry SB, Mandell VS, Keane JF, Rome JJ, Bittl JA, et al. Transcatheter umbrella closure of valvular and paravalvular leaks. J Am Coll Cardiol. 1992;20:1371–1377[Abstract]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Arkalgud Sampath Kumar Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hussain, S. T. Articles by Sampath Kumar, A. Search for Related Content PubMed PubMed Citation Articles by Hussain, S. T. Articles by Sampath Kumar, A.