Mickey Mouse in the cath lab

Abstract

A 70-year-old man with severe combined mitral and aortic regurgitation submitted to double bio-prosthetic valve replacement was readmitted for increasing shortness of breath 3 months after surgery. At trans-oesophageal echocardiography (TEE), 2 large mitral paravalvular leaks (PVLs), in antero-lateral andmedial position respectively, were imaged (Fig. 1). Deeming trans-catheter PVL closure at higher cost–benefit than surgical re-do, the patient's informed consent to the procedure and agreement of cardiac surgeons were obtained. The procedure was performed under general anaesthesia with fluoroscopic and 3D-TEE guidance, mostly with the latter, since the bio-prosthetic valves did not show any radiographic landmarks. Trans-septal antegrade approach was used to negotiate the PVLs with a 0.035′′ hydrophilic Terumo guide-wire (Terumo Medical Corp., Somerset, New Jersey) and to sequentially implant 2 Amplatzer Vascular Plug type II 12 mm (St. Jude Medical Corp, St. Paul, MN, USA) devices (Fig. 2). After final deployment, mild intra-prosthetic residual flow was imaged, without any interference with the valve. At the end of the procedure, the mitral bio-prosthesis/plug complex funnymimicked a Mickey Mouse picture at 3D-TEE (Video 1, Fig. 3). Post-procedural course was uneventful and the patient was discharged on day 4. The present report aims at highlighting the pivotal role of 3D-TEE in successfully guiding and monitoring all steps of PVL percutaneous closure, mainly in challenging settings with scarce support available from other imaging tools.