Abstract
Regurgitant jet lesions are often encountered in patients with paravalvular leak (PVL) and may pose significant challenge to percutaneous PVL closure. This report describes the case of a 78-year-old female with severe mitral PVL with an associated jet lesion in the left atrium and illustrates its successful percutaneous management. (Level of Difficulty: Intermediate.)
Key Words: hemolysis, mitral regurgitation, paravalvular leak, percutaneous closure
Abbreviations and Acronyms: PVL, paravalvular leak; TEE, transesophageal echocardiogram
Graphical abstract
Regurgitant jet lesions are often encountered in patients with paravalvular leak (PVL) and may pose significant challenge to percutaneous PVL closure…
Case Report
A 78-year-old female presented with progressive dyspnea. Medical history included hypertension, diabetes, atrial fibrillation, obstructive pulmonary disease, 2 remote coronary bypass operations, and subsequent mitral valve replacement for severe degenerative mitral regurgitation (27-mm Carpentier-Edwards porcine bioprosthesis; Edwards Lifesciences, Irvine, California). No history of endocarditis was documented. Outside transesophageal echocardiography (TEE) suggested the presence of severe paravalvular leak (PVL). Workup also revealed moderate hemolysis (hemoglobin, 8.9 g/dl [reference, 11.2 to 15.2 g/dl], lactate dehydrogenase, 507 U/l [reference, 125 to 220 U/l], haptoglobin, <3 mg/dl [reference, 30 to 200 mg/dl]) but no evidence of endocarditis. Due to the prohibitive surgical risk, percutaneous PVL closure was planned. Intraprocedural TEE, however, showed a highly mobile pediculated lesion (0.5 × 1.5 cm) at the intersection between the PVL jet and the lateral left atrial wall (Figure 1A, Video 1). Differential diagnoses included endocarditis, thrombus, tumor, or jet-related lesion. Given her negative cultures and the characteristics of the lesion, it was felt that a jet-related lesion was the likely diagnosis. Cerebral embolic protection was considered but was not possible due to an occluded right radial artery and small brachial artery. Hence, it was decided to proceed with PVL closure, exercising extra caution with catheter manipulation near the lesion under TEE guidance.
Figure 1.
3D TEE Illustrating PVL Closure in the Setting of the Jet Lesion
(A) Large anterolateral mitral PVL (dotted red line) and an adjacent mobile atrial lesion (black arrow). (B) Real-time TEE showing stabilization of the lesion with the atrial desk of the vascular plug. (C, D) Sequential deployment of the second and third plugs. See Videos 1 and 2. Ant = anterior; AV = aortic valve; IAS = intra-atrial septum; LAA = left atrial appendage; Lat = lateral; Med = medial; Pos = posterior; TEE = transesophageal echocardiography.
Online Video 1.
Baseline 3D-TEE imaging showing the PVL with its associated jet lesion. 3D = three dimensional; TEE = transesophageal echocardiography.
An Agilis sheath (St. Jude Medical, Saint Paul, Minnesota) was steered toward the PVL (Video 2). The leak was crossed with a mother-and-daughter system (6- to 4-F multipurpose catheters) and a 0.035-inch angled stiff glide wire (Terumo, Tokyo, Japan). A venoarterial rail was established by externalizing the wire through a 6-F arterial sheath (Supplemental Figure 1). A sequential anchor wire technique was used to deploy 3 (12-mm) Amplatzer Vascular-II plugs (St. Jude Medical) to reduce the PVL to trivial size (Video 2). The jet lesion became more mobile during catheter manipulation but was eventually stabilized by the atrial desks of the plugs (Figures 1B to 1D, Video 2). The patient was discharged 3 days later and experienced significant reduction in her dyspnea and incidence of hemolysis at 1 month (hemoglobin, 11.7 g/dl; lactate dehydrogenase, 298 U/l; haptoglobin, 103 mg/dl). Symptomatic improvement was persistent at the 6-month follow-up.
Online Video 2.
Real-time 3D-TEE imaging illustrating the procedure steps. 3D = three dimensional; TEE = transesophageal echocardiography.
Discussion
Regurgitant jet-related lesions have been described in the setting of infectious endocarditis 1, 2. However, the present patient had negative blood cultures and no history of endocarditis. The authors speculated that the lesion was due to the long-standing effect of the severe eccentric PVL directed at and eroding into the left atrial wall. It is possible that such lesions predisposed the patient to future endocarditis. Current advances in imaging techniques may allow early identification of jet-related lesions, which can trigger an earlier intervention that may reduce the change of future endocarditis (3).
Footnotes
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Appendix
For a supplemental figure and videos, please see the online version of this paper.
Appendix
References
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