Abstract
Background
An 81-year-old man with 2 prior mitral valve replacements developed recurrent symptomatic paravalvular leak (PVL) despite prior transcatheter closure with vascular plugs. He had ongoing heart failure hospitalizations and hemolytic anemia that limited uninterrupted anticoagulation in the setting of atrial fibrillation and high thromboembolic risk.
Case Summary
The patient underwent a combined procedure with redo PVL closure and left atrial appendage occlusion. Given close anatomic proximity of the lateral PVL to the appendage ostium, a Watchman FLX Pro device was deployed to achieve both left atrial appendage occlusion and sealing of the lateral PVL. Postprocedure, mitral PVL resolved, hemolysis improved at 1-month follow-up, and PVL closure was durable on 3-month follow-up transesophageal echocardiography.
Discussion
To our knowledge, this is the first report of Watchman device use for mitral PVL closure. In high–surgical risk patients with atrial fibrillation and bleeding limitations, this single-device strategy may simplify treatment and reduce the need for additional interventions.
Key words: chronic heart failure, imaging, mitral valve, valve replacement
Graphical Abstract
Visual Summary.
Patient Timeline
AVP II = Amplatzer Vascular Plug II; CABG = coronary artery bypass grafting; LAAC = left atrial appendage closure; MVR = mitral valve replacement; PVL = paravalvular leak; TAVR = transcatheter aortic valve replacement; TEER = transcatheter edge-to-edge repair.
Case Summary
An 81-year-old man was assessed for both mitral paravalvular leak (PVL) closure and left atrial appendage (LAA) closure. He had multiple recent hospitalizations for decompensated heart failure requiring intravenous diuretics as well as hemolytic anemia requiring transfusion with ongoing NYHA functional class III/IV symptoms. On examination, he had a grade 4/6 holosystolic murmur that was loudest at the apex radiating toward the axilla; there was no peripheral edema, lungs were clear, and abdomen was benign.
Take Home Messages
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Multimodality imaging can identify selected cases where a left atrial appendage closure device can be deployed to achieve both appendage closure and sealing of an adjacent lateral mitral paravalvular leak.
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In high–surgical risk patients with atrial fibrillation and bleeding limitations, this single-device strategy may simplify treatment and reduce the need for additional interventions.
The patient's history included paroxysmal atrial fibrillation, coronary artery disease, and rheumatic mitral valve disease. He had previously undergone single-vessel coronary artery bypass grafting and mitral valve replacement (MVR) with a 29-mm Perimount valve (Edwards Lifesciences). Seven years later, he underwent redo MVR with a 31-mm St Jude Epic valve (Abbott) for partial dehiscence; operative cultures were negative for endocarditis. Three months after MVR, there was recurrent symptomatic severe mitral regurgitation due to PVL, without evidence of endocarditis. There were 3 PVLs, 1 lateral and 2 medial. The lateral defect was closed with two Amplatzer Vascular Plug II (AVP2) devices (14-mm and 12-mm; Abbott), while the largest medial defect was closed with one 10-mm AVP2 plug. Mean left atrial pressure was reduced from 24 to 16 mm Hg, and mild to moderate PVL remained from the smallest medial defect. Unfortunately, over the next year the patient continued to have heart failure hospitalizations and worsening anemia, with evidence of hemolysis secondary to residual PVL along with gastrointestinal arteriovenous malformations, which made continuous anticoagulation challenging. This was problematic given his high risk of stroke or systemic embolism related to his atrial fibrillation and valve disease (CHA2DS2-VASc score: 7). In addition, the patient was prescribed a 3-month course of apixaban 2.5 mg twice daily for a recent small pulmonary embolism. Repeat transthoracic echocardiography showed normal biventricular function, bioprosthetic mitral valve with 3 paravalvular jets, with moderate to severe mitral regurgitation, mean mitral gradient of 4 mm Hg, and severe tricuspid regurgitation (Video 1, Video 2, Video 3).
In light of the persistent PVL complicated by recurrent heart failure and hemolysis, persistent atrial fibrillation and tenuous anticoagulation status, the decision was made to undergo combined repeat PVL closure and LAA closure. The procedure was performed under general anesthetic with transesophageal echocardiography (TEE) guidance. TEE showed persistence of the previously seen medial PVL as well as recurrent lateral PVL and a new posterior PVL site resulting in overall severe paravalvular regurgitation with systolic flow reversal in the pulmonary veins (Figures 1A and 1C). The posterior PVL was closed using a 12-mm AVP2, while the medial PVL was closed with another 12-mm device, reducing both jets to trace. We then turned our attention to the recurrent lateral PVL; after close assessment of the location in relation to the LAA ostium (Figures 1B and 1C), we hypothesized that a Watchman device could be deployed in a manner to achieve both appendage occlusion and PVL closure.
Figure 1.
Preprocedural and Postprocedural Imaging
(A) Preprocedure 3D echocardiography with color Doppler showing medial (right), lateral (left) and posterior (bottom) PVL. (B) Preprocedure cardiac computed tomography showing site of previous AVP2 and persistent PVL in relation to the LAA ostium. (C) Preprocedure image showing lateral PVL jet entering the LAA ostium. (D) Postprocedure color Doppler showing minimal residual lateral PVL at the site of the Watchman device (asterisk). (E) Postprocedure 3D echocardiography with color Doppler showing AVP2 devices and Watchman device in situ (asterisks) without remaining PVL. (F) Postprocedure en face fluoroscopy view of the mitral annulus. 3D = 3-dimensional; AVP2 = Amplatzer Vascular Plug II; LAA = left atrial appendage; PVL = paravalvular leak.
We deployed a 31-mm Watchman FLX Pro device (Boston Scientific) in the appendage. We then reassessed the lateral PVL jet and found it was also sealed by the Watchman device with only trace PVL remaining and abolishment of retrograde pulmonary vein systolic flow (Figures 1D to 1F, Video 1). The mean left atrial pressure dropped from 33 to 29 mm Hg, and the V wave dropped from 65 to 49 mm Hg, which was a significant improvement although it remained chronically elevated in keeping with a stiff left atrium. Predischarge transthoracic echocardiography showed preserved left ventricular function, stable device position, no mitral regurgitation, mitral mean gradient 4 mm Hg, and residual severe tricuspid regurgitation. The patient was discharged the following day in stable condition with a personalized antithrombotic plan of apixaban 2.5 mg twice daily for 2 months to complete pulmonary embolism treatment, with repeat TEE to assess for device-related thrombus prior to de-escalation to aspirin 81 mg single antiplatelet therapy.
When the patient was seen at 1-month follow-up, his hemoglobin had stabilized, and hemolytic markers including lactate dehydrogenase and bilirubin had significantly improved (Table 1). However he was still experiencing symptoms of right heart failure, therefore he subsequently underwent tricuspid valve TEER 3 months after PVL and LAA closure, at which time TEE confirmed stable lateral PVL closure with the Watchman device and only trace residual PVL, with no device-related thrombus (Videos 4 and 5).
Table 1.
Hemolytic Biomarkers at Baseline and During Postprocedural Follow-Up
| Baseline: October 15 2025 | Postprocedure: November 24 2025 | Postprocedure: February 23 2026 | |
|---|---|---|---|
| Hemoglobin (g/L) | 77 | 84 | 102 |
| Lactate dehydrogenase (IU/L) | 2,122 | 839 | 1,222 |
| Bilirubin (μmol/L) | 124 | 45 | 46 |
| Haptoglobin (g/L) | <0.01 | <0.01 | <0.01 |
The procedure was performed on October 29, 2025. Biomarkers significantly improved after the procedure and were maintained out to available 4-month follow-up. The persistent abnormalities are attributed largely to chronic liver disease, including cirrhosis.
Procedural Steps
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Right common femoral vein preclosed with a Perclose ProStyle (Abbott).
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Transseptal puncture with VersaCross (Boston Scientific) performed at a midposterior location; sheath advanced into the left atrium and wire positioned in the left upper pulmonary vein.
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Interatrial septum further dilated using a 4-mm Mustang balloon (Boston Scientific).
Posterior PVL Closure
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Posterior PVL crossed with Agilis NXT small-curve steerable introducer (Abbott) and 260-cm angled Glidewire (Terumo).
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A 4-F MP diagnostic catheter was advanced across the PVL.
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A 260-cm Amplatz Extra-Stiff wire (Cook Medical) was advanced through the catheter into the left ventricular apex.
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A 6-F MP guide catheter with telescoping 4-F MP was advanced over the Amplatz Extra-Stiff wire.
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A 12-mm AVP2 was deployed. Residual PVL was assessed by TEE/color Doppler and found to be none/trace.
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Medial PVL closed using the same sequence (crossing with Agilis and angled Glidewire, catheter/wire exchange, and deployment of a 12-mm AVP2), with TEE confirmation of none/trace residual PVL.
LAA + PVL Closure
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VersaCross wire advanced into the left atrium and positioned at the LAA ostium.
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Watchman fixed curve sheath (Boston Scientific) advanced to the LAA ostium.
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Pigtail catheter advanced into the LAA for angiography.
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Watchman FLX Pro device deployed under fluoroscopic and TEE guidance; position, seal, and compression confirmed, including a tug test, before release. Lateral mitral PVL reduced to trace.
Potential Pitfalls
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Insufficient support to advance guide catheter across calcified/tortuous PVL tract. Solutions: 1) exchange Amplatz Extra-Stiff wire for a Lunderquist wire to increase rail support; 2) create an arteriovenous loop (eg, snare a wire advanced into the left ventricle/aorta) to improve deliverability.
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Residual lateral PVL after Watchman deployment (incomplete “dual seal”). Solutions: Before device release, recapture and reposition the Watchman to optimize coverage of the PVL orifice while maintaining LAA seal/compression. If residual PVL persists, pre-cross the lateral PVL with Agilis + angled Glidewire before final Watchman release to maintain access, then deploy an appropriately sized AVP2 (or alternative occluder) to close the remaining jet.
Discussion
Atrial fibrillation is common after cardiac surgery and is associated with an increased risk of stroke and systemic thromboembolism, a risk that is particularly elevated in patients with mitral valve disease. In atrial fibrillation, most thromboembolic strokes are believed to originate from left atrial thrombus, with >98% of left atrial thrombi forming in the LAA.1 In patients undergoing cardiac surgery, LAA ligation has been shown to reduce stroke by 33%.2 In elderly patients, the coexistence of atrial fibrillation and high bleeding risk is common, and transcatheter LAA closure with the Watchman device has emerged as a safe and effective strategy to reduce embolic risk in patients who cannot tolerate uninterrupted long-term oral anticoagulation.3
PVL occurs in up to 17% of patients after MVR, with approximately 5% being clinically significant.4 Based on current guidelines, surgical repair has traditionally been considered the gold-standard treatment, albeit supported largely by nonrandomized observational data.4 With advances in transcatheter PVL closure—demonstrating high procedural success and low complication rates—percutaneous therapy has become first-line for many patients with suitable anatomy at high risk for redo surgery. However, PVL can recur after closure through several mechanisms, including progressive atrial and ventricular remodeling, further suture failure, calcification, and/or poor tissue integrity (the likely mechanism in our case). This case demonstrates that a lateral mitral annular PVL adjacent to the LAA ostium, in a patient with atrial fibrillation and high bleeding risk, is amenable to closure with a Watchman device. Such an approach may reduce the need for additional vascular plugs that could remain susceptible to PVL recurrence through the same mechanisms observed in this patient. In terms of device selection, other devices such as the Amulet could also be used with careful anatomical preprocedural planning. For this specific case we preferred the Watchman device, as its shoulder design would have had the most favorable interaction with the mitral annulus PVL site to provide sufficient closure. If the LAA closure device does not provide adequate PVL closure, this can be managed as outlined in the Potential Pitfalls section.
In this case, information from preprocedural computed tomography and intraprocedural 2-dimensional/3-dimensional TEE was integrated to guide device selection and procedural sequencing. This multimodal analysis is what led to the hypothesis that the lateral PVL could be adequately closed with the Watchman device and highlights the importance of systematic, detailed multimodality imaging when planning complex structural heart interventions, enabling a more personalized strategy tailored to patient-specific anatomy.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
Appendix
For supplemental videos, please see the online version of this paper.
Appendix
Procedural Steps for Combined Left Atrial Appendage and Mitral Paravalvular Leak Closure
Includes baseline images and immediate post LAA closure result and reduction in lateral PVL.
Lateral PVL Jet Involving the Left Atrial Appendage Ostium Before Watchman Closure
3D With Color Doppler Before Watchman Closure
2D Lateral PVL Site With Watchman In Situ at 3 Months After the Procedure Showing Stable Reduction in PVL
3D of Mitral Valve at 3-Month Follow-Up With Color Doppler Showing Durable Result With Trace Residual Lateral and Medial PVL
References
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Associated Data
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Supplementary Materials
Procedural Steps for Combined Left Atrial Appendage and Mitral Paravalvular Leak Closure
Includes baseline images and immediate post LAA closure result and reduction in lateral PVL.
Lateral PVL Jet Involving the Left Atrial Appendage Ostium Before Watchman Closure
3D With Color Doppler Before Watchman Closure
2D Lateral PVL Site With Watchman In Situ at 3 Months After the Procedure Showing Stable Reduction in PVL
3D of Mitral Valve at 3-Month Follow-Up With Color Doppler Showing Durable Result With Trace Residual Lateral and Medial PVL