CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 6, November/December 2011
AFRICA
e7
Case Report
Percutaneous closure of a tricuspid paravalvular
leak with an Amplatzer duct occluder II via antegrade
approach
A IYISOY, H KURSAKLIOGLU, T CELIK, O BAYSAN, M CELIK
Abstract
Paravalvular leaks are seen after valve-replacement surgery
and most patients with these leaks are asymptomatic, prob-
ably due to the small size of the leak. Nevertheless, a para-
valvular leak after tricuspid valve replacement is a rare
complication and may cause severe haemoylsis and hepatic
dysfunction. It is usually treated surgically. There are no data
on percutaneous transcatheter closure of paravalvular leaks.
In this report, we present a successful percutaneous closure
of a paravalvular leak using an Amplatzer duct occluder II
device after a tricuspid valve replacement in a patient with
high operative risk who had also had mitral and aortic valve
replacements.
Keywords:
tricuspid valve replacement, paravalvular leak,
percutaneous transcatheter closure
Submitted 26/1/10, accepted 31/8/10
Cardiovasc J Afr
2011;
22 (6)
: online publication
DOI: 10.5830/CVJA-2010-079
Almost 210 000 valve-replacement surgeries are performed
worldwide annually.
1
A paravalvular leak (PVL) is a poten-
tial complication of cardiac valve-replacement surgery and
may cause severe haemoylsis or haemodynamic instability.
2
In such cases, haemolysis rarely resolves spontaneously and
usually requires a further operation. Re-operation is associated
with higher rates of morbidity and mortality. Also, the risk of
recurrent paravalvular insufficiency is high after re-operation.
Although, there is no specifically designed transcatheter device
available for repair of paravalvular leaks, percutaneous transcath-
eter closure of a PVL may be a promising alternative to surgery.
In this report, we present a case of successful percutaneous
closure of a tricuspid PVL using an Amplatzer duct occluder
(ADO) II device under the guidance of three-dimensional (3D)
transoesophageal echocardiography (TEE) in a patient in whom
severe haemolysis and hepatic dysfunction had developed due to
a PVL after tricuspid valve replacement.
Case report
A 57-year-old man with aortic and mitral valve replacements
five years earlier, and a tricuspid valve replacement with a
31-mm St Jude Medical valve prosthesis three years earlier, was
admitted to our hospital for congestive heart failure (NYHA,
class III). Laboratory examination revealed severe haemolysis
(serum haemoglobin 9.8 g∕dl, reticulocyte count 3.8%, lactic
dehydroxygenase (LDH) 1 080 U/l). The left ventricular ejec-
tion fraction measured 40% and a localised moderate PVL was
shown on transoesophageal echocardiography (TEE) (Fig. 1).
The patient was symptomatic and the operation was very high
risk because of the two previous valve operations. The standard
Euroscore of the patient was calculated at 6 points (estimated
mortality 10.9–11.5%). Percutaneous closure of this PVL was
decided on and informed patient consent was obtained.
The procedure was performed under general anaesthesia
with the guidance of 3D TEE. After heparinisation, a 6F multi-
purpose diagnostic catheter was placed into the right atrium. A
0.035-inch straight-tipped glide wire (Terumo Inc, Japan) was
advanced into the right ventricle passing through the PVL site,
and confirmed with 2D and 3D TEE. Subsequently, a 6F multi-
purpose diagnostic catheter was advanced through the defect.
The glide wire was then changed with a 0.035-inch super-stiff
Amplatzer guidewire (260 cm).
The delivery system was placed into the right ventricle over
this extra-stiff wire. The ADO II device (waist diameter 6 mm,
disc diameter 12 mm) was screwed to the delivery cable, loaded
Department of Cardiology, Gulhane Military Medical
Academy, School of Medicine, Ankara, Turkey
A IYISOY, MD
H KURSAKLIOGLU, MD
T CELIK, MD
O BAYSAN, MD
M CELIK, MD,
Fig. 1. Transoesophageal echocardiography showing
moderate to severe tricuspid paravalvular regurgitation.
White arrow shows PVL. RA: right atrium, LA: left atrium,
PVL: paravalvular leak.
