Transcatheter Closures for Fistula Tract and Paravalvular Leak after Mitral Valve Replacement and Tricuspid Annuloplasty
A 71 year-old man was admitted due to exertional dyspnea (New York Heart Association functional class III). He had a past medical history of pericardiectomy due to effusive-constrictive pericarditis 29 years ago and mitral valve replacement with tricuspid annuloplasty due to severe mitral and tricuspid regurgitation 11 years ago. His electrocardiogram showed atrial fibrillation with controlled ventricular rhythm. Transthoracic echocardiography showed abnormal shunt flow from the aorta to the right atrium, a tissue defect in the mitral annulus with moderate PVL (distal jet area of 7 cm2), mild tricuspid regurgitation with mild resting pulmonary hypertension (maximal velocity of tricuspid regurgitation jet=3.2 m/s), and an enlarged left ventricle with near normal systolic function (end-diastolic dimension of the left ventricle=67 mm, ejection fraction=51%). Transesophageal echocardiography (TEE) also revealed continuous abnormal shunt flow through a fistula tract from the aorta (noncoronary cusp) to the right atrium (), and about a 4-5 mm sized tissue defect in the mitral annulus with moderate PVL (). On computed tomography, about a 3 mm PVL was observed at the lateral aspect of the mitral annulus (). His calculated logistic EuroSCORE and STS risk score were 16.7% and 7.0%, respectively. After discussion with both the surgical and interventional teams, we decided to perform staged transcatheter closures for both the fistula tract and mitral PVL.\nThe first procedure was conducted under general anesthesia with fluoroscopic and TEE guidance. A 7 French (Fr) sheath was inserted through the right femoral vein and 6 Fr sheaths were placed in both femoral arteries. A 6 Fr pigtail catheter was inserted through the right femoral artery. After a peripheral angiogram with a pigtail catheter, we confirmed the existence of a fistula tract between the aorta and right atrium. The fistula tract could be crossed with a 260 cm long 0.032 inch Terumo wire, and it was confirmed by TEE. A 6 Fr Cournand catheter was advanced into and passed through the defect. Another 6 Fr Cournand catheter was introduced into the right atrium (). Using a Curry intravascular retriever, the guidewire was captured and withdrawn through the right femoral sheath. The guidewire was exchanged for a 0.035 inch stiff wire using a 6 Fr Cournand catheter. The 6 Fr Cournand catheter was replaced with an 8 Fr delivery sheath that was advanced into the ascending aorta. Because the sizes of the tissue defect on TEE were 9 mm in length and 4 mm in width, we selected an 8/6 mm sized Amplatzer duct occluder. After proper device positioning, which was confirmed using fluoroscopy and TEE, the device was deployed ( and ). Immediate TEE showed a well-positioned device, and disappearance of the abnormal shunt flow between the aorta and right atrium ().\nAfter the first procedure, his symptoms improved slightly and a follow-up echocardiography two months after the first procedure showed slightly decreased left ventricular diastolic dimension with reduced ejection fraction (from 51% to 46%) and persistent resting pulmonary hypertension. Percutaneous closure of the PVL was attempted to decrease left ventricular volume overloading. Under general anesthesia, a 7 Fr sheath was inserted through the right femoral vein and a 6 Fr sheath was inserted through the right femoral artery. A TEE was also used for guidance. A pigtail catheter was placed into the posterior cusp of the aortic valve through the right femoral artery. The sheath in the right femoral vein was exchanged for a Mullin sheath and dilator, which was advanced over a 0.032-inch guidewire into the superior vena cava. Thereafter, the guidewire was removed and a Brockenbrough needle was gently advanced to within a few millimeters of the tip of the dilator, and the needle was flushed and connected to a manifold for continuous pressure monitoring. With fluoroscopic guidance (RAO 45 degrees), the interatrial septum was punctured at the site of the fossa ovalis. The Mullin sheath was advanced into the left atrium. The stainless steel wire was crossed over the tissue defect in the mitral annulus. Using a 6 Fr multipurpose catheter, the stainless steel wire was exchanged for a 0.035 inch stiff wire (). After several dilatations with a septal dilator, the 8 Fr delivery sheath was placed in the left ventricle. Because the defect size on the TEE was about 4-5 mm, we also chose an 8/6 mm sized Amplatzer duct occluder. After proper device positioning was confirmed on the TEE, the device was deployed (). The TEE that was performed immediately afterwards showed a well-positioned device and a trivial PVL (). At 24 hours post-procedure, transthoracic echocardiography also showed well-positioned devices and no remnant shunt flow or PVL. Echocardiography immediately after the procedure showed persistent left ventricular dysfunction (ejection fraction=47%) but disappearance of resting pulmonary hypertension.