Page 15 - Journal of Structural Heart Disease Volume 3, Issue 5

Case Report
Journal of Structural Heart Disease, October 2017, Volume 3, Issue 5:141-146
DOI: https://doi.org/10.12945/j.jshd.2017.019.17
Transcatheter Closure of a Mitral Valve
Paravalvular Leak in an Infant
Received: April 21, 2017 Accepted: May 3, 2017 Published online: October 2017
Ugonna Nwankwo, MD*, James Goldsmith, MD, Sara Trucco, MD, Jacqueline Kreutzer, MD Department of Cardiology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
Abstract
Mitral valve replacement, which is a relatively rare procedure in young children, can be complicated by paravalvular leaks (PVLs). Here, we report the rst suc- cessful percutaneous treatment of a PVL in an infant. The patient was a 7-month-old, 6 kg boy with a histo- ry of Shone’s complex after aortic arch reconstruction and balloon valvuloplasty of the mitral valve. Due to severe mitral insu ciency, he underwent mitral valve replacement with a 16-mm Medtronic open-pivot AP 360 mechanical aortic valve in the supra-annular mi- tral position at 5 months of age. He developed a pos- terior PVL post-operatively with persistent hemolysis requiring repeated transfusions. Medical therapy with pentoxifylline failed. Thus, 2 months post-op- eratively, he was referred for percutaneous cardiac catheterization for PVL closure. Transesophageal echocardiography (TEE) identi ed a small PVL be- tween the mouth of the left atrial appendage and the left upper pulmonary vein. A trans-septal approach was utilized. Using a Cobra catheter, a 0.018” oppy wire was advanced from the venous sheath through the leak and into the ascending aorta, where it was snared by a multisnare introduced from the arterial sheath. A 4-mm Amplatzer vascular plug II was then positioned anterogradely and successfully deployed in the tract. No signi cant leak was visualized by an- giography or TEE, and the child’s hemolysis subsided. Our case demonstrates that device closure of mitral valve PVL in a very small child is technically feasible and may obviate repeat surgery.
Key Words
Catheterization • Paravalvular regurgitation • Prosthetic • Mitral valve • Pediatric
Introduction
Paravalvular prosthetic valve leak (PVL) is a po- tentially signi cant complication of surgical valve re- placement, with a reported incidence of up to 18% for aortic valves and 23% for mitral valves in adult pa- tients [1]. Many factors can contribute to PVL due to an incomplete seal between the prosthetic ring and native valve annulus, including annular calci cation, infection, suboptimal surgical technique, suboptimal prosthesis sizing, or any cause of tissue friability [2]. Although a small PVL is often asymptomatic, it can lead to signi cant hemolysis, whereas moderate or large PVLs can manifest with signs and symptoms sec- ondary to increased hemodynamic burden, including pulmonary hypertension and congestive heart failure [3]. In young children, mitral valve replacement is a relatively rare procedure, and there are limited data on PVL intervention in children under 12 months old. To our knowledge, this is the rst reported case of transcatheter paravalvular leak closure in a child un- der 12 months of age.
Case Presentation
Appropriate signed consent was obtained. The pa- tient was a 7-month-old, 6 kg boy born with Shone’s variant consisting of coarctation of the aorta, bicus- pid aortic valve, and congenital mitral valve stenosis. On the rst day of life, he was taken to the operating room for coarctectomy and aortic arch reconstruc- tion. He initially did well but developed progressive mitral stenosis with associated respiratory distress, feeding intolerance, and failure to thrive, for which he
* Corresponding author:
Ugonna Nwankwo, MD
Sibley Heart Center Cardiology
Children’s Healthcare of Atlanta
1405 Clifton Rd NE, Atlanta, GA 30322, USA
Tel.: +1 336 391 6621; Fax: + 1 770 488 9431; E-Mail: nwankwou@kidsheart.com
Fax +1 203 785 3346
E-Mail: jshd@scienceinternational.org http://structuralheartdisease.org/
© 2017 Journal of Structural Heart Disease Published by Science International Corp. ISSN 2326-4004
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