A 36-year-old male underwent mitral valve replacement with a single leaflet mechanical prosthesis for rheumatic chronic severe mitral regurgitation associated with cardiac cachexia, chronic atrial fibrillation, and severe pulmonary hypertension. His postoperative period was complicated by uncontrolled heart failure, recurrent refractory pericardial and pleural effusions, warranting creation of surgical pleuro pericardial window through a left anterolateral thoracotomy. A mild mitral paravalvular leak adjacent to the left atrial appendage on third post-operative day progressively enlarged to 16 mm at 2 months (Figure 1, Movie 1) leading to referral to our centre. Cardiac catheterization after 2 months showed near systemic pulmonary artery pressures. The left atrial v-waves and mean pressures after transseptal puncture were 86 and 46 millimetres of mercury (Figure 2). Closure of the leak through transseptal sheaths (Figure 3, Movie 2) with 2 large 16 mm and 10 mm Amplatzer muscular ventricular septal defect occluders (Abbott, Plymouth, MN, USA) reduced the left atrial pressures to 35 millimetres of mercury. However, both devices embolized within a few minutes and started floating like butterflies in the left atrium due to the impact of the paravalvular regurgitation jet (Figure 4, Movie 3). Immediate surgical retrieval on cardiopulmonary bypass through a redo sternotomy and suture of the leak led to early recovery. Risk factors for embolization of paravalvular leak devices include very large regurgitant orifices, more than one interlocking device and inadequate annular fibrosis in an acute postoperative setting.1),2) On a follow-up of 6 years, he was asymptomatic with normal prosthesis function and permanent atrial fibrillation.
展开▼
