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A 54-year-old woman with previous valvular surgery and permanent atrial fibrillation was admitted due to congestive heart failure. In 2005, she underwent open-heart surgery when mitral valve was replaced (31-mm On-X mitral valve [CryoLife, Inc.]). Also a tricuspid annuloplasty (34-mm Edwards MC3 ring [Edwards Lifesciences]) and a left atrial appendage (LAA) ligation were completed. A transesophageal echocardiography showed a lateral paravalvular leak (12 × 6 mm) in the prosthetic mitral valve (Fig. 1A). Percutaneous closure of the paravalvular leak was performed (Fig. 1B, C) with an Amplatzer Vascular Plug III device (12 × 5 mm) (St. Jude Medical) with no residual regurgitation detected (Fig. 1D, E). Subsequent to this, the patient was admitted because of recurrent cardioembolic strokes despite optimal treatment with warfarin. Cardiac imaging evaluation detected a residual communication between the left atrium and previously ligated LAA (Fig. 1F) and a percutaneous closure was decided upon. After a LAA angiogram identified incomplete ligation (Fig. 1G), a 16 mm Amplatzer Vascular Plug II device (St. Jude Medical) was placed via 8 Fr Mullins sheath which sealed the orifice with no residual flow (Fig. 1H, I). Incomplete LAA closure following surgical ligation occurs in 30–40% of cases and is associated with a significantly increased risk of thrombus formation/thromboembolism. Although, percutaneous closure of incomplete ligation has been previously described, according to available research, this is the first reported case of a complete percutaneous repair of two complications after valvular surgery.

Complete percutaneous repair after valvular surgery