A case study of paravalvular leak closure

Priyanka1*, Nagajothi2, Sri Preethi3, Jaya Menon4

1StaffNurse, Kauvery Hospital, Heart city, Trichy, Tamil Nadu

2Nursing In-charge, , Kauvery Hospital, Heart city, Trichy, Tamil Nadu.

3Nursing Educator, , Kauvery Hospital, Heart city, Trichy, Tamil Nadu

4Nursing Superintendent, , Kauvery Hospital, Heart city, Trichy, Tamil Nadu

*Correspondence

Abstract

Paravalvular leak (PVL) is a recognized complication following prosthetic valve replacement and may cause significant mitral regurgitation and symptoms of heart failure. A 56-year-old male with coronary artery disease and rheumatic heart disease, who had undergone mitral valve replacement with a 29-mm TTK Chitra mechanical prosthetic valve, presented with dyspnea on exertion for one month. Transesophageal echocardiography revealed severe mitral paravalvular leak with severe mitral regurgitation. The patient underwent successful percutaneous PVL device closure using Amplatzer Vascular Plug II devices measuring 10 × 7 mm and 12 × 9 mm under TEE and fluoroscopic guidance. Post-procedure assessment showed successful leak closure without significant residual PVL or procedural complications. The patient demonstrated clinical improvement and was discharged in stable condition. This case highlights the role of percutaneous PVL closure as a minimally invasive treatment option for symptomatic PVL following mechanical mitral valve replacement.

Keywords: Paravalvular leak; Mitral valve replacement; Mechanical prosthetic valve; Mitral regurgitation; AVP II; TEE; Percutaneous PVL closure.

Introduction

Paravalvular leak (PVL) is a potential complication following prosthetic valve replacement, occurring due to an abnormal passage between the prosthetic valve and surrounding annular tissue. Significant PVL can result in mitral regurgitation, heart failure symptoms, hemolysis, and reduced functional capacity. A 56-year-old male with known coronary artery disease and rheumatic heart disease underwent mitral valve replacement with a 29-mm TTK Chitra mechanical prosthetic valve on 27/11/2023. He presented with dyspnea on exertion for one month. TEE revealed severe paravalvular leak with severe mitral regurgitation. The patient was referred to as percutaneous PVL device closure and underwent successful closure using AVP II devices under TEE and fluoroscopic guidance. This case highlights the importance of appropriate evaluation and minimally invasive management of symptomatic PVL following mechanical mitral valve replacement.

Case Presentation

The patient is a 56 year with dyspnea on old male who presented excretion for approximately one month. He had no history of chest pain ‘Sweating palpitations, pedal edema, giddiness. He had abdominal pain, nausea or was previously evaluated at another hospital and was referred to Anbu hospital for further management. He is a disease with underwent PLI known case of coronary artery a history of Acs in with 2020. He DES to the RCA in 2020/25/11. He also has history of rheumatic heart replacement with disease and underwent Mitral valve 29mm TTK chitra prosthetic mono leaflet mitral valve on 27/11/2023 at Omandur Hospital. He was subsequently evaluated and found to have Significant paravalvular leak (PVL) associated with severe mitral regurgitation for Which he was referred for trans catheter PVL device closure

Investigations

Lab reports

InvestigationsValue
HB14.5g/dl
PCV48.1%
Total RBC6.46 X 106 /µL
MCV74.5
Total WBC11230 cells/cumm
Neutrophil65.2%
Lymphocyte19.8%
Platelet9.5%
PT(Test)15.9sec
PT(Control)10.7sec
INR1.49
Urea33mg/dl
Creatine1.4mg/dl
Na+130meq/l
K+3.7meq/l

Other Investigations

ECG

RhythmNSR with ventricular bigeminy
PR88ms
QRS115ms
QTC494ms
  • LAE (+)
  • LVH

ECHO: Hypokinesia of inferior segment of LV(+) mild LVSD, LV LA dilated, normally functioning prosthetic valve in mitral position severe MR, Sever PAH, thin pericardial effusion (+).

CT scan: (Lung)

  • Moderate cardiomegaly metallic Mitral Valve prothesis noted.
  • Post-operative sternal wire noted.

ECG

After Procedure image

During Procedure image

Diagnosis

  • CAD S/P-CAG-SVD
  • S/P -PTCA to RCA (2020)
  • S/P-MVR (2023)
  • Severe MR / Severe paravalvular leak PVL device closure (8/8/26) with AVP -II 10X 7mm and 12X9mm device.

Relevant clinical findings

Patient Profile

  • 56-year-old male
  • Diagnosed with RHD, severe MR and CAD
  • Mitral Valve Replacement with a 29mm TTK Chitra prosthetic Mono leaflet mitral valve on 27/11/23.

Clinical Findings

  • Difficulty in breathing. NVHA class III for 1 month
  • Intermittent chest pain
  • Intermittent palpitation no history of leg swelling, syncope, cough, hemoptysis.

Management

Initial Management

  • Managed for sever mitral regurgitation with acute pulmonary edema.
  • Anemia was corrected with 3 units PRBC transfusion.
  • Renal function was monitored because of AKI on CKD
  • Appropriate diuretics and other cardiac medications were continued as prescribed
  • Anticoagulation (Antithrombotic therapy) was managed according to the patient’s prosthetic valve Status and treating cardiologist plan.

Surgical management

Pre procedure

  • PA-67/33mmhg Mean-45
  • Aortic pressure-148/96mmhg, Mean 114
  • LA pressure Vwave-53mmhg, mean-27mmhg.

Post procedure

  • LA pressure -V wave -20mmhg, mean-13mmhg.
  • Aortic pressure-206/117mmhg.

Nursing management

Preprocedural

  • Assess vital signs, spo2 and cardiac status
  • Check ECG and relevant investigations (CBC, Coagulation, renal function, electrolytes)
  • Confirm informed consent and procedure preparation
  • Check allergies, especially contrast /medication allergies.

During procedure

  • Monitor, HR, Spo2 and ECG continuously
  • Maintain Strict aseptic technique
  • Assist in preparation of vascular access site and equipment
  • Monitor contrast administration and observe for allergic reactions
  • Administer Sedation, anticoagulants and other drugs as prescribed
  • Assist the Cardiac team during device deployment
  • Monitor for arrhythmias hypotension, bleeding and hemodynamic instability.

Post procedure

  • Monitor, HR, Spo2 and ECG continuously
  • Check access sites for bleeding, hematoma or swelling
  • Assess distal pulse, dour, temperature and capillary refill
  • Monitor urine output Contrast exposure and renal function after
  • Administer prescribed anticoagulants / antiplatelets and other medications
  • Encourage fluids and gradual mobilization as ordered
  • Educating regarding Signs and follow up medication’s adherence warning.

Post procedure outcome

The procedure was complete without procedural complications. The patient was monitored in the CCU and received supportive management. Post procedure echocardiography demonstrated no residual paravalvular leak and the patient symptoms improved, he was subsequently discharged in a stable condition

Discussion

  • Surgical PVL occurs due to leakage around a prosthetic heart valve.
  • Surgical repair involves re-exploration and closure of the leak using sutures or a patch.
  • Valve replacement may be required if the prosthetic valve is damaged or unstable.
  • Surgical treatment carries risk such as bleeding, infection, stroke and arrhythmias.
  • Percutaneous PVL closure is a minimally invasive alternative to redo surgery in selected patients.
  • In this case, the patient underwent percutaneous PVL closure with good post-procedure results and no complications noted.

Nursing Discussion

  • Monitor vital signs, ECG and SpO₂ before and after the procedure.
  • Maintain aseptic technique and prepare the patient for the procedure.
  • Monitor vascular access site for bleeding, hematoma and infection.
  • Observe for arrhythmias, hypotension, chest pain and breathing difficulty.
  • Monitor urine output and renal function after contrast administration.
  • Administer prescribed antiplatelet/anticoagulant and cardiac medications.
  • Encourage gradual mobilization and provide adequate rest.
  • Educate the patient about medication adherence, warning signs and follow-up.
  • Proper documentation and continuous observation help ensure safe recovery and early detection of complications.

Outcome

Following the procedure, the patient was monitored in the CCU and managed with supportive treatment. Post-procedure echocardiography showed no significant residual paravalvular leak, with improvement in the patient’s clinical condition. He was subsequently discharged in stable condition.

Conclusion

This case demonstrates the successful use of transcatheter PVL closure with AVP II devices for significant paravalvular mitral regurgitation following prosthetic mitral valve replacement. Careful imaging guidance with TEE and fluoroscopy enabled accurate device deployment and an excellent procedural outcome.

References

  1. ConcRuiz, C. E., Jelnin, V., Kronzon, I., Dudiy, Y., Pradhan, M., Chiam, P. T. L., Rihal, C. S., & O’Neill, W. W. (2011). Clinical outcomes of percutaneous transcatheter closure of paravalvular leaks. Journal of the American College of Cardiology, 58(21), 2218–2224.
  2. Sorajja, P., Cabalka, A. K., Hagler, D. J., Malouf, J. A., Reeder, G. S., & Suri, R. M. (2011). Long-term follow-up of percutaneous repair of paravalvular prosthetic regurgitation. JACC: Cardiovascular Interventions, 4(8), 875–881.
  3. Ruiz, C. E., Cohen, H., Del Valle-Fernández, R., Jelnin, V., Perk, G., Kronzon, I., & Ferrari, M. (2015). Closure of prosthetic paravalvular leaks: A systematic review and meta-analysis. European Heart Journal, 36(9), 547–556.Sorajja, P., Cabalka, A. K., Hagler, D. J., Malouf, J. A., Reeder, G. S., & Suri, R. M. (2011). Long-term follow-up of percutaneous repair of paravalvular prosthetic regurgitation. JACC: Cardiovascular Interventions, 4(8)

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment