A Case Demonstrating a Percutaneous Closure Using the Amplatzer Duct Occluder for Paravalvular Leakage after Tricuspid Valve Replacement
A 51-year-old woman was diagnosed with ASD at the age of 10 years. However, her disease had not been clinically managed until she presented with cough and palpitation at the age of 37 years. At that time, a large secundum ASD (30×20 mm), rheumatic mitral valve regurgitation of grade 2/4, and tricuspid valve regurgitation of grade 2/4 by incomplete coaptation were identified by transthoracic echocardiography (TTE). Electrocardiography showed atrial fibrillation. Cardiac catheterization revealed a right ventricular end diastolic pressure of 5 mm Hg, left ventricular end diastolic pressure of 5 mm Hg, and mean pulmonary artery pressure of 20 mm Hg, respectively. Since both ventricular functions were good without any evidence of pulmonary hypertension, ASD closure was performed using a Bovine pericardial patch at 37 years of age. TTE after ASD closure showed that the pressure gradient of tricuspid regurgitation of grade 2-3/4 was 33 mm Hg, the right ventricle and the right atrium were enlarged, and both ventricular functions were normal.\nHowever, as time passed, regurgitation flow of the tricuspid valve had progressed and valvular annuluses had been dilated by atrial fibrillation. Additionally, there were degenerative valve changes and occurrence of annular dilatation due to valve regurgitation itself. Besides, by rheumatic changes and atrial fibrillation, regurgitation flow of the mitral valve had also progressed. At ten years of age after ASD closure, she suffered from recurrent respiratory infection and decreased exercise capacity. TTE revealed an enlarged right ventricle which was also severely dysfunctional, tricuspid valve regurgitation of grade 4/4, and annular dilatation. In addition, the enlarged left ventricle had mitral regurgitation of grade 2/4 as well as annular dilatation. Hence, we performed tricuspid valve replacement (TVR) by 29 mm perimounted Carpentier-Edwards (Edwards Lifesciences, Irvine, CA, USA), mitral valve repair, mitral annuloplasty with a 28 mm Carpentier-Edwards ring (Edwards Lifesciences, Irvine, CA, USA), and Maze III operation with cryoablation. During the post-operative period, she had right ventricular dysfunction that required extracorporeal membrane oxygenation but the patient was weaned off on day 10 after the cardiac operation. TTE demonstrated a well functioning tricuspid valve and mild tricuspid regurgitation in the central and paravalvular areas.\nShe has been admitted to the hospital several times after TVR due to recurrent heart failure, respiratory infections, and pleural effusions. Five years after the valve replacement operation, TTE showed a moderate amount of tricuspid valve regurgitation via PVL with a dilated inferior vena cava and decreased right ventriclular function (). Due to ventricular dysfunction and a history of post-operative mechanical support, she refused surgery to correct her condition at that time. Thus, we opted for percutaneous device closure of the PVL.\nPercutaneous closure was performed via an antegrade femoral approach under general anaesthesia with trans-esophageal echocardiogram (TEE) and fluoroscopic guidance. The PVL was located in the medial side of the tricuspid valve. The defect was selected by an angled hydrophilic guidewire of 0.035 inches (Glide wire, Terumo Inc., Japan) and the diameter of the leak measured by right ventriculography was 7.8 mm. Therefore, we chose the Amplatzer duct occluder (ADO) for deployment because of its "double flange" configuration. An ADO measuring 12×10 mm was positioned in the paravalvular defect and in TEE, mild tricuspid valve regurgitation was found owing to the elliptical nature of the defect (). By day 5, tricuspid valve regurgitation became mild, likely due to the seating of the device and edema of the surrounding tissues. Repeat TTE in the third month post-procedure showed the device to be well seated, and both ventricles demonstrated good function. Early complications, including stroke, embolism, arrhythmia and infection, were absent. After 14 months, the patient showed improvement in her respiratory symptoms and the New York Heart Association function class returned from IV to II.