CARDIOVASCULAR JOURNAL OF AFRICA • Vol 22, No 6, November/December 2011
e8
AFRICA
into the sheath, and passed across the PVL. The distal disc was
opened and then placed into the orifice of the PVL. Subsequently,
the proximal disc was opened in the right atrium. The device was
released after establishing that the position of the device was
correct (Fig. 2). Closure of the defect was demonstrated with
3D TEE and complete disappearance of the leak was confirmed
with 2D TEE (Fig. 3). The total procedural time was 32 minutes
and fluoroscopy time was 11 minutes. The post-procedure course
was uneventful with normal prosthetic valve function.
Discussion
Paravalvular regurgitation is a complication of prosthetic cardiac
valve placement. This may occur soon after or many years post
surgery. Small PVLs can be detected in up to half of the patients,
using echocardiographic imaging. Larger defects are detected in
3 to 7.5% of patients with valve replacements and the detection
rate has increased if TEE is used.
3
PVLs are most often found in association with mitral valve
prostheses, less often with aortic, and only rarely with pulmo-
nary or tricuspid valve prostheses.
4
PVLs may develop more
commonly in patients with heavy annular calcification and
localised infection.
5
Technical mistakes, including incomplete
apposition of the sewing ring to the native tissue or breaks in one
of the sutures may lead to dehiscence and PVLs.
6
Most cases of PVLs are small. They have little clinical signifi-
cance and tend to improve or disappear over time. However,
severe perivalvular regurgitation may lead to some symptoms.
These leaks can cause haemolytic anaemia as a result of red cell
fragmentation in the high shear-stress regurgitant jet, decreased
exercise tolerance or dyspnoea as a result of congestive heart
failure, pulmonary hypertension and infective endocarditis.
1,7
Spontaneous closure has rarely been encountered. Medical
therapy is usually palliative and directed at the congestive heart
failure or haemolysis. Re-operation is the gold-standard therapy
for symptomatic patients with PVLs, but it is associated with
a higher mortality and morbidity rate than that of the initial
operation.
8
Also, re-operations are associated with increased
risk of PVLs.
9
Percutaneous repair of perivalvular regurgitation
has been proposed as an alternative therapy to avoid the risk of
surgery.
Hourihan
et al
.
10
in 1992 reported the first successful percu-
taneous closure of a PVL, using a Rashkind umbrella device in
a patient with an aortic paravalvular leak. Over the years, many
devices have been used for percutaneous closure of PVLs, which
are often irregular, tortuous and frequently crescent-shaped. The
success rate of this procedure depends on the type of PVL and
the shape of the closure device. Regurgitation may persist due to
incomplete closure of the PVL because of an unsuitable shape of
device for the leak.
There is no specifically designed transcatheter device
approved for percutaneous closure of PVLs. ADO II, which is
designed for closing a patent ductus arteriosus, has a circular
shape with two discs and a smaller waist size. Therefore, anADO
II device can provide effective closure for PVLs and improve-
ment of symptoms. For these reasons, an ADO II device was
used in our case. Using periprocedural transoesophageal echo-
cardiography provided important anatomical details and helped
in optimal device selection and delivery.
Despite this technically feasible and safe treatment modality,
there are few reported cases of percutaneous closure of PVLs.
Most have been involved with the mitral valve, and a successful
percutaneous closure of an aortic PVL was reported. There is no
reported case in the literature of a transcatheter closure of a PVL
after tricuspid valve replacement. This is probably a result of the
few patients receiving tricuspid valve replacements, not because
of technical difficulties. To the best of our knowledge, this is the
Fig. 3. Two-dimensional transoesophageal echocardio-
graphy after deployment of the closure device shows the
paravalvular regurgitation has completely disappeared.
RA: right atrium, LA: left atrium, PVL: paravalvular leak.
Fig. 2. The cine-angiography shows the glide wire and 6F multipurpose diagnostic catheter advanced into the right
ventricle passing through the PVL site (A). The glide wire was changed to a 0.035-inch super-stiff Amplatzer guide
wire, which was subsequently advanced into the pulmonary artery (B). Releasing the ADO II device after viewing with
transoesophageal echocardiography (C).
A
B
C
