Preservation Of Subvalvular Apparatus Research Articles

C36 NON–CYCLIC INTERMITTENT PROSTHETIC MITRAL VALVE DYSFUNCTION: A CASE REPORT OF A DIFFICULT DIAGNOSIS CONFIRMED WITH MULTIMODALITY IMAGING

Abstract A 59–year–old man,obese,with history of hypertension, 3 years ago underwent mitral valve (MV) replacement with a mechanical prothesis(Sorin Bicarbon 31) and preservation of the native subvalvular apparatus for severe mitral regurgitation due to anterior leaflet flail. Pre–discharge transthoracic echocardiography (TTE) showed normal prothesis function (mean pressure gradient (PG) 3,2mmHg), no valvular leaks and a normal ejection fraction (EF). Lately, the patient was admitted twice to emergency department for signs of heart failure, solved with increasing dose of oral diuretics. In both cases a TTE showed a normal EF, a trans–prosthetic mean PG of 6,5mmHg and no valvular impairment/leaks. Since the suboptimal TTE acoustic windows, a transesophageal echocardiography (TEE) was recommended. TEE showed a normal motion of both MV discs and no pannus/thrombus or leaks with the use of a 2–beat acquisition protocol. However, with longer observation a pattern of non–cyclic intermittent valve dysfunction was noted: whereas some cardiac cycles showed normal discs’ motion, other cycles demonstrated an emi–disc opening delay or blockage during diastole with significant prolongation of transmitral pressure half–time and higher transvalvular gradient, suggestive of flow impairment. A cine fluoroscopy and a CT assessment were also performed, showing the visible intermittent pattern of valve dysfunction without radiological signs of thrombosis or pannus. At this point, the interference of the MV apparatus with the emidisc was considered the most probable mechanism of dysfunction. A Heart Team decision toward reintervention was taken since the risk of a sudden worsening of the mechanical valve function, with potentially lethal consequences, was considered high. The surgeon at visual inspection confirmed the interference of the subvalvular apparatus with the posterior emidisc motion. The chronic shear stress generated on the mitral remnant likely developed a progressive fibrotic response that determined the thickening of the tissue and the periodical entrapment of the disc. MV prothesis was replaced with resection of the subvalvular apparatus. At dismissal,TTE evaluation showed normal valvular function confirmed at 6 months follow–up. Intermittent prosthetic MV dysfunction is a rare but potentially serious complication of MV replacement with subvalvular apparatus preservation. TEE, cine–fluoroscopy and CT may be useful as complementary tools to detect this rare complication.

Commentary: "Postoperative Changes in Left Ventricular Systolic Function after Combined Mitral and Aortic Valve Replacement in Patients with Rheumatic Heart Disease" Sang-Mee An, MD, Jae-Sik Nam, MD, Ho Jin Kim, MD, PhD, Hyeun Joon Bae, MD, Ji-Hyun Chin, MD, PhD, Eun-Ho Lee, MD, PhD, In-Cheol Choi, MD, PhD.

It is an elegant albeit limited study reporting effects of pre op LVEF on long term results in patients with RHD undergoing DVR. Study includes 146 patients out of 201 who underwent DVR in the study period. Although all had some improvement immediate post op, those with preserved ejection fraction (EF) and smaller left ventricles regardless of type of prostheses used, surgical techniques (partial or full Subvalvular Apparatus Preservation), had more sustained improvement after 3-4 years than those with lower EF and more dilation. It can be partially explained by more prevalence of aortic insufficiency in patients with pre op lower EF <50 and dilation (average left ventricular end systolic dimension 49 vs. 32 mm in EF >50). There are myocardial factors which also play a part, those with abnormal left ventricle (LV) function have more extensive loss of myofibrils either due to disproportion of mitochondria-to-myofibril ratio or myofibrillar degeneration exhibiting the extent RHD involves myocardium. Structural adaptation may not all be just a result of hemodynamic abnormalities in these patients. The recommendation that surgical intervention should occur before the LV starts to dilate or EF drops is well founded and would be impactful in the developing world, an estimated 250,000 deaths occur annually worldwide and 10.5 million disability adjusted life years due to RHD, mostly in young people.

Mitral kapak replasmanı için yen bir biliflet koruma tekniği: Lafçı'nın katlama tekniği

Sub-valvular apparatus preservation procedure is an additional technique to mitral valve replacement which decrease the prevalence of low cardiac output syndrome and associated complications that may be seen after mitral valve replacement. A number of surgical techniques for both bileaflet and posterior leaflet preservation have been described previously. We aimed to share how we do the bileaflet preservation with a modified technique, Lafci’s anterior leaflet fold down technique, in selected patients who underwent mitral valve replacement procedure.With absence of resection and use of same sutures for both sparing leaflet and fixing mechanical valve may shorten cross-clamping time, and so, we believe that this technique is simple, reproducible when it is appropriate for the patient’s existing anatomy.

EARLY MORTALITY &amp; MORBIDITY IN MITRAL VALVE REPLACEMENT WITH TOTAL SUB-VALVULAR APPARATUS PRESERVATION, PARTIAL PRESERVATION AND NO PRESERVATION - A COMPARATIVE STUDY

Objective: To compare the early morbidity &amp; mortality of total sub-valvular apparatus preservation technique vs partial preservation technique and no preservation technique in mitral valve replacement.&#x0D; Study Design: Cross-sectional comparative study.&#x0D; Place and Duration of Study: Department of Cardiac Surgery, Armed Forces Institute of Cardiology Rawalpindi, from Jan 2017 to Dec 2018.&#x0D; Methodology: One hundred fifty seven patients who underwent Mitral valve replacement were included in study. These patients were divided into three groups; group “A” comprised of those patients with total subvalvular apparatus preservation (n1=46), group “B” comprised of those patients with partial sub-valvular apparatus preservation (n2=70), group “C” comprised of those patients with no sub-valvular apparatus preservation(n3=41).&#x0D; Results: There were no statistical difference in the pre-operative data of the patients. No statistical difference noted in cross clamp &amp; bypass time (p&gt;0.05). The early morbidity in terms of ICU stay, Ventilation time, Inotropic supports, post-operative bleeding, Blood transfusion, postoperative rhythm abnormality &amp; Re-exploration were statically significant (p&lt;0.05). The mortality rate of patients with total sub-valvular apparatus preservation was 2.17% which is significantly less than those with partial preservation (2.85%) &amp; no preservation (9.75%).&#x0D; Conclusions: Mitral valve replacement with total subvalvular apparatus preservation had low postoperative morbidity &amp; mortality in comparison with partial and no preservation techniques.

IMPACT OF THE PRESERVATION OF THE SUBVALVULAR APPARATUS OF THE ANTERIOR MITRAL LEAFLET ON THE LEFT VENTRICULAR FUNCTION AFTER MITRAL VALVE REPLACEMENT IN EARLY POST-OPERATIVE PERIOD

Background:Long-term morbidity and mortality appear to be associated with mitral valve replacement for mitral valve disease. The morbidity rate has not decreased dramatically over the years, despite enhancements in myocardial safety and prosthetic valves. Cardiac failure is the most common cause of death following MVR. Subvalvular apparatus preservation preserves LV function and thus improves survival. Repair, particularly with rheumatic valve disease in young patients and extremely disorganised valves, is not always feasible or effective. The use of smaller valve prothesis was not only the argument of preserving the anterior leaflet, but also that it could cause LVOT obstruction. Methods:A prospective controlled randomized study will include(sixty patients aged from 25 to 55 years of both sexes) They will be divided into two groups of patients: Group I: thirty patients who underwent MVR without preservation of The chordae tendinae of the anterior mitral leaflet and only preserving the posterior mitral leaflet. Group II: thirty patients who underwent MVR with complete or partial Preservation of the chordae tendinaeof the anterior mitral leaflet. Results:The sixty patients were divided into two groups where 30 of them underwent preservation of AML, These patients had a better LV function in the early and the short term postoperative period. Conclusion:Results of this study concluded that preservation of the AML leads to better postoperative outcome. We recommend its application on a greater scale of cases of MVR.

Mitral Valve Replacement Using Subvalvular Apparatus: A Systematic Review and Meta-Analysis.

To assess clinical outcomes among participants undergoing mitral valve replacement with preservation of subvalvular apparatus. Electronic databases, including PubMed, Embase, Science Direct, World of Science, Scopus, Biosis, SciElo and Cochrane library, were probed using an extensive search strategy. Studies that reported at least one clinical outcome, such as morbidity, mortality, early 30-day mortality, myocardial failure, survival, late cerebrovascular events, length of stay, or major operative complications (stroke, prolonged ventilation, and reoperation for bleeding, renal failure, and sternal infection) were considered for inclusion. Data was extracted and pooled into a meta-analysis in RevMan (version 5.3) using a random-effects model. A total of 21 studies with 5,106 participants (age range: 27.3-69.2 years) were included in this meta-analysis. Preservation of the subvalvular apparatus during MVR significantly reduces the risk of long-term mortality (OR: 0.46; 95% CI: 0.33-0.64), but not early mortality (OR: 0.76; 95% CI: 0.12-4.93). No significant difference ejection fraction was observed (SMD: 0.10; 95% CI: -0.44-0.64). Similarly, there was no significant difference in the risk of stroke, renal failure, and pneumonia between C-MVR and in the control group. MVR with the preservation of subvalvular apparatus improves clinical outcomes, such as long-term mortality, hospital length of stay, pneumonia, and bleeding. There is no significant difference in the risk of stroke, renal failure, or ICU length of stay. However, there is very limited data available with respect to bleeding, sepsis, and nosocomial infections.

Outcome analysis for prediction of intraaortic balloon pump support failure and long-term survival in high-risk patients undergoing mitral valve surgery.

The outcome predictors of intra-aortic balloon pump (IABP) in patients who undergo mitral valve surgery remain unknown. This study aimed to retrospectively review valvular surgery in patients who received an IABP to identify the predictors of failure of IABP support and anticipate the necessary therapy. This retrospective observational study recruited a total of 157 consecutive patients who underwent open-heart mitral valve surgery with IABP implantation intraoperatively or postoperatively. Univariate and multivariate logistic regression analyses were performed to identify the risk factors attributed to 30-day mortality. Follow-up data of survivors were collected to investigate the effect of IABP support to evaluate long-term outcomes. The overall 30-day mortality was 35.7% (56 patients). The following factors that contributed to 30-day mortality included sepsis (P<.001, OR: 5.627, 95%CI: 2.422-11.683); IABP implantation postoperatively rather than intraoperatively (P=.001, OR: 6.395, 95%CI: 2.085-19.511); right heart failure (P=.042, OR: 3.419, 95%CI: 1.225-12.257); and lack of subvalvular apparatus preservation (P=.033, OR: 3.710, 95%CI: 1.094-13.167). Furthermore, follow-up data of these patients showed an estimation of 5-year and 10-year survival rates of 58.9% and 35.7%, respectively. Patients with intraoperative IABP demonstrated better long-term survival outcomes when compared to those with postoperative IABP (χ2 =4.291, P=.038). In summary, this study distinguished the preoperative predictors of 30-day mortality of IABP-support in mitral valve surgery patients. These results indicated that early intervention with IABP should be taken into consideration in case of hemodynamic instability in critically ill patients undergoing mitral valve surgery.

IMMEDIATE AND LONG-TERM OUTCOMES AFTER BIOPROSTHETIC MITRAL VALVE REPLACEMENT WITH THE PRESERVATION OF THE SUBVALVULAR APPARATUS

Aim. To assess the immediate and long-term outcomes after bioprosthetic mitral valve replacement with the preservation of the subvalvular apparatus. Methods. 304 patients who underwent primary bioprosthetic mitral valve replacement in the period from 2001 to 2009 were included in the study. Patients were enrolled into two groups with either preserved subvalvular structures (Group 1. n = 142, 47%) or resected structures (Group 2, n = 162) during bioprosthetic mitral valve replacement. For the unbiased assessment of the efficiency of valve-preserving approach, randomly selected patients from Group 1 (n = 75) and Group 2 (n = 40) underwent preoperative and postoperative invasive monitoring of the central hemodynamics using the Swan-Ganz thermodilution catheter. Results In-hospital mortality was 1.4% (n = 2) in Group 1 and 4.3% in Group 2. The most common cause of death was acute left ventricular failure. We found that the preservation of subvalvular structures allows ensuring the optimal linear and volumetric echocardiography parameters in the immediate postoperative period, despite the hemodynamic profile of the defect. However, the positive effects were more pronounced in patients with more severe mitral regurgitation. Patients with preserved subvalvular structures had more durable surgical mitral valve replacement according to the echocardiographic findings in the long-term period. The invasive monitoring of central hemodynamics allowed determining that total subvalvular apparatus preservation was associated with more significant pressure decline in the pulmonary circulation (mean pulmonary arterial pressure and pulmonary capillary wedge pressure) and improved cardiac index and output. Posterior leaflet preservation was associated with less pronounced changes and patients who underwent routine mitral valve replacement had the worst intermediate outcomes. Conclusion The results of the presented study suggest that the preservation of subvalvular apparatus, unless otherwise indicated, is associated with improved immediate and long-term outcomes after mitral valve replacement.

Short Term Clinical Outcome in Patients with Mitral Valve Replacement with or without Preservation of Subvalvular Apparatus

Background: Preservation of subvalvular apparatus (SAP) during mitral valve replacement (MVR) was introduced about forty years back, but the outcome of this procedure is not well studied yet. Our study aimed to measure the in-hospital outcome of this procedure in rheumatic patients.Method: 44 patients of rheumatic heart disease undergoing for MVR in the department of cardiac surgery, BSMMU were enrolled for the study. The technique of SAP was according to choice of surgeon. Patients were divided into two groups- I) with preservation: complete preservation, where entire chordo-papillary apparatus was preserved &amp; partial preservation, where posterior leaflet was preserved, II) no preservation: where subvalvular apparatus was completely excised. Surgical technique was different according to patient’s requirement and one of either technique was adopted by Fuster et al or Miki et al. Patients’ demographic profile and mitral valve status were recorded. Outcome was recorded in terms of hemoynamic outcome and in hospital death. Data was analyzed by Chi squired test.Result: Mean±SD of age of patients was 32±8 years, 29±7years in group-I, 36±9years in group-II. There was no significant difference in age distribution between two groups. Both groups were female predominant, 82% in group-I and 73% in group-II. Low cardiac output syndrome was observed in 4.5% of group-I and 32% in group-II (P-value was &lt;0.001). Left ventricular failure was observed as 0% &amp; 32% respectively (p value was &lt;0.001). Inotropic agent was needed 45% &amp; 75% respectively (p value was &lt;0.01). In hospital death occurred in 4.5% &amp; 13.5% in two groups respectively with no significant difference.Conclusion: Hemodynamic outcome and in hospital mortality was better when subvalvular apparatus was preserved during mitral valve replacement in rheumatic population.University Heart Journal Vol. 12, No. 1, January 2016; 3-7

Effects of subvalvular apparatus preservation in mitral valve replacement among rheumatic patients: early and mid term follow up.

Effects of subvalvular apparatus preservation in mitral valve replacement among rheumatic patients: early and mid term follow up.

Acquired discrete subaortic stenosis late after mitral valve replacement

Although acquired left ventricular outflow obstruction has been reported in a variety of conditions, there are scant reports of its occurrence following mitral valve replacement (MVR). This study describes two female patients, who developed severe discrete subaortic stenosis, five years following MVR. In both cases, the mitral valve was replaced by a porcine Carpentier-Edwards 27-mm bioprosthesis with preservation of mitral valve leaflets. The risk of very late left ventricular outflow tract obstruction after bio-prosthetic MVR with preservation of subvalvular apparatus needs to be kept in mind in symptomatic patients.

Mitral valve sub valvular apparatus preservation in pure or predominant rheumatic mitral stenosis

Surgery of the mitral valve is an important part of the surgical activity at Algerian heart surgery departments. In many cases the lesions exceed the possibility of native valve preservation, thus requiring the replacement thereof. When replacing, conservation of the subvalvular apparatus or not remains a question which had a real interest, which was reflected in the significant number of studies on the subject. The majority of these studies have demonstrated the value of subvalvular apparatus preservation on the future of ventricular function in the immediate and distant; however almost all of these studies have concerned patients with mitral insufficiency lesions.

Papillary Muscle Repositioning as a Subvalvular Apparatus Preservation Technique in Mitral Stenosis Patients with Normal Left Ventricular Systolic Function

Subvalvular apparatus preservation is an important concept in mitral valve replacement (MVR) surgery that is performed to remedy mitral regurgitation. In this study, we sought to determine the effects of papillary muscle repositioning (PMR) on clinical outcomes and echocardiographic left ventricular function in rheumatic mitral stenosis patients who had normal left ventricular systolic function. We prospectively assigned 115 patients who were scheduled for MVR surgery with mechanical prosthesis to either PMR or MVR-only groups. Functional class and echocardiographic variables were evaluated at baseline and at early and late postoperative follow-up examinations. All values were compared between the 2 groups. The PMR group consisted of 48 patients and the MVR-only group of 67 patients. The 2 groups' baseline characteristics and surgery-related factors (including perioperative mortality) were similar. During the 18-month follow-up, all echocardiographic variables showed a consistent improvement in the PMR group; the mean left ventricular ejection fraction deteriorated significantly in the MVR-only group. Comparison during follow-up of the magnitude of longitudinal changes revealed that decreases in left ventricular end-diastolic and end-systolic diameters and in left ventricular sphericity indices, and increases in left ventricular ejection fractions, were significantly higher in the PMR group than in the MVR-only group. This study suggests that, in patients with rheumatic mitral stenosis and preserved left ventricular systolic function, the addition of papillary muscle repositioning to valve replacement with a mechanical prosthesis improves left ventricular dimensions, ejection fraction, and sphericity index at the 18-month follow-up with no substantial undesirable effect on the surgery-related factors.

Mitral Kapak Aparatusunun Korunması: Bileaflet ve Monoleaflet Karşılaştırması (Orta Dönem Sonuçları)

Objective: The aim of this study was to compare the midterm results in terms of cardiac mechanics and clinical outcomes for monoleaflet versus bileaflet protection in preserving the subvalvular apparatus in patients who underwent mitral valve replacement. Material and Methods: This study consists of the retrospective analysis of 51 consecutive non-randomized patients who underwent mitral valve replacement (MVR) between 2001 and 2007 in our clinic. Twenty five of them had total (group I) and 26 had partial (group II) chordal preservation operation. We compared clinical preoperative and postoperative conditions as well as the characteristics of the valve and left ventricle between the groups. The choice of the chordal preservation method depended on the surgeon's decision. Results: At the end, all patients were in functional class I-II. No in-hospital mortality was observed. Clinical improvement was observed in both groups, but reductions in percentage of (preoperative/mid-term postoperative period) change of left ventricular end-systolic (LVES), left ventricular end-diastolic (LVED), left atrial (LA) diameters (all of p<0.001) and pulmonary artery pressure (PAP) (p<0.01) were more prominent in patients with complete preservation of the mitral apparatus. In-group comparisons showed no significant difference in terms of ejection fraction between percentage of change values in both groups (p=0.144). Conclusion: Although no significant difference was observed in cardiac performance between the two groups, echocardiographically determined superior reductions of LVESD, LVEDD, LAD and PAP in patients with complete preservation of the mitral apparatus may suggest that whenever possible, preservation of whole subvalvular apparatus in mitral valve replacement confers a significant advantage to the patients.

全弁下組織温存僧帽弁置換術後に合併した乳頭筋断裂の1例

全弁下組織温存僧帽弁置換術後に合併した乳頭筋断裂の1例

The Impact of Sub-valvular Apparatus Preservation on Prosthetic Valve Dysfunction During Mitral Valve Replacement.

Background:Sub-valvular apparatus preservation (SAP) during mitral valve replacement (MVR) is not a new concept. Some surgeons prefer to excise the apparatus.Objectives:The aim of this study was to reduce the risk of prosthetic valve dysfunction.Materials and Methods:This retrospective study included 151 patients with the mean age of 46 years who underwent MVR (Female/male = 93/58). In the group I consisting of 39 patients, MVR with chordae preservation was performed (Bi-leaflet preservation = 20; posterior leaflet preservation = 19). In the group II consisting of 112 patients, sub-valvular apparatus was resected completely during MVR. Preoperative patients’ characteristics, including age, sex, functional status, left ventricular ejection fraction, and end-diastolic or end-systolic dimensions were statistically similar in both groups. Mean follow-up period was 60.3 ± 26 months.Results:The improvement of functional status was seen in almost all survivors but was more obvious in the group I. In early follow-up, 56.4% of group I cases and 44.1% of group II patients were classified as New York Heart Association class I. These rates were 84.2% and 71.2% in mid-term follow-up, respectively (P < 0.001). Mortality rate was significantly lower in the group I (2.6%) compared to the group II (8.9%) (P = 0.03). There was a trend for higher frequency of postoperative atrial fibrillation in the group II compared to that in the group I (52.7% vs. 38.5%, P = 0.12).The incidence of prosthetic valve dysfunction (PVD) was 5.1% in the group I and 4.5% in the group II, but this difference was not statistically significant (P = 0.56).Conclusions:Preservation of mitral annulus and papillary muscle continuity may enhance post- MVR cardiac performance with low mortality and morbidity rates. The risk of PVD was not significantly higher than conventional MVR in our series.

Early bioprosthetic valve failure caused by preserved native mitral valve leaflets

The importance of preservation of subvalvular apparatus and valve-ventricular continuity during mitral valve replacement (MVR) has been suggested for many years. The chordal-sparing MVR has been shown to be superior to the standard MVR with chordal resection in terms of improved left ventricular function and has been considered to be a safe procedure. However, we encounter a rare case requiring early reoperation for bioprosthetic valve failure caused by preserved leaflets after chordal-sparing MVR.

Does preservation of the sub-valvular apparatus during mitral valve replacement affect long-term survival and quality of life? A Microsimulation Study

BackgroundTechniques to preserve the sub-valvular apparatus in order to reduce morbidity and mortality following mitral valve replacement have been frequently reported. However, it is uncertain what impact sub-valvular apparatus preservation techniques have on long-term outcomes following mitral valve replacement. This study investigated the effect of sub-valvular apparatus preservation on long-term survival and quality of life following mitral valve replacement.MethodsA microsimulation model was used to compare long-term survival and quality-adjusted life years following mitral valve replacement after conventional valve replacement and sub-valvular apparatus preservation. Probabilistic sensitivity analysis and alternative analysis were performed to investigate uncertainty associated with the results.ResultsOur Analysis suggests that patients survive longer if the sub-valvular apparatus are preserved (65.7% SD 1.5%, compared with 58.1% SD 1.6% at 10 years). The quality adjusted life years gained over a 10 year period where also greater after sub-valvular apparatus preservation. (6.54 QALY SD 0.07 QALY, compared with 5.61 QALY, SD 0.07 QALY). The superiority of preservation techniques was insensitive to patient age, parameter or model uncertainty.ConclusionThis study suggests that long-term outcomes may be improved when the sub-valvular apparatus are preserved. Given the lack of empirical data further research is needed to investigate health-related quality of life after mitral valve replacement, and to establish whether outcomes differ between preservation techniques.

Preservation of the mitral valve apparatus: evidence synthesis and critical reappraisal of surgical techniques

Sub-valvular apparatus preservation after mitral valve replacement is not a new concept, yet to date there has been no quantification of its clinical effectiveness as a procedure and no consensus as to which surgical preservation technique should be adopted to achieve the best immediate and midterm clinical outcomes. This systematic review of current available literature aims to use an evidence synthesis and meta-analytic approach to compare outcomes following replacement of the mitral valve with (MVR-P) or without preservation (MVR-NP) of its apparatus. It considers all the relevant anatomical, experimental, echocardiographic, and clinical studies published in the literature and appraises all reported mitral valve sub-valvular apparatus preservation techniques. The results of this review strongly suggest that MVR-P is superior to MVR-NP with regards to the incidence of early postoperative low-cardiac output requiring inotropic support, and early or mid-term survival. They also suggest that the operative decision should be individualised based on patient's anatomy, pathology and ventricular function and therefore surgeons should be familiar with more than one surgical preservation technique. Finally, this paper highlights the need for further high quality research focusing particularly on the long-term assessment of quality of life and health utility following MVR-P.

Feasibility of preservation of subvalvular apparatus in mitral valve replacement with the On-X mechanical valve

ration of suture material, technical mistakes, or acute infection. Surgical intervention to repair the leak improves symptoms of heart failure, decreases the need for blood transfusion, and is an independent predictor of long-term survival when compared with medical therapy alone. The choice of operation involves either direct suture repair of the PVL or rereplacement of the valve and is indicated to correct worsening left ventricular function or symptoms of heart failure and hemolysis. Although surgical intervention has been the gold standard for the repair of PVLs, there has been a growing interest in the attempt to close PVLs through the use of interventional cardiologic techniques. Several reports have documented the successful percutaneous repair of PVLs with closure devices similar to those applied for the percutaneous treatment of septal defects. Percutaneous closure has several advantages, including the elimination of the risk of a redo operation and shortening the length of hospital stay. Nevertheless, the procedure is complex, time consuming, and not always successful, as illustrated in this case. Successful intraoperative device closure of muscular ventricular septal defects has previously been reported. However, to our knowledge, the case presented herein is the first reported use of the intraoperative placement of a percutaneous occluder device for the surgical repair of a PVL. This novel approach for the repair of a mitral PVL can be applied in the context of extremely difficult mitral prosthesis exposure, such as the presence of a concurrent aortic prosthesis, or to avoid lengthy redo operations in very high-risk patients.