In May 2023, a 66-year-old woman was referred for New York Heart Association functional class III fatigue and exertional dyspnea due to severe paravalvular leakage (PVL) of her prosthetic mitral valve (MV). Her medical history included scarlet fever and rheumatic heart disease, with six previous open heart surgeries (OHS) from 1986. Especially the trido-mitral valve replacement (MVR) performed to correct the mitral annular disruption in 2000.

In echocardiography, a Dshaped left ventricular (LV) cavity with preserved LV ejection fraction and adilated right ventricular (RV) cavity with depressed RV systolic function wereconfirmed. Also, diffuse severe PVL of the prosthetic MV with rocking motionwas shown at 5-8 o’clock in Surgeon’s view.
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In cardiaccatheterization, group 2 pulmonary hypertension was also combined with adecreased cardiac index (C.I.) (LV end diastolic pressure 33 mmHg, mean pulmonaryartery pressure 49 mmHg, C.I. 1.89). Considering the high peri-operative (OP)risk and severe intra-thoracic adhesion, we planned percutaneous PVL closure.

The patient wasplaced under general anesthesia. After gaining access through the right femoralvein, we performed a transseptal puncture. Under transesophagealechocardiography (TEE) guidance, we advanced a guidewire transeptally throughthe area of the PVL into the ascending aorta. Then, successfully, we placed a12x9-mm vascular plug in the PVL area. However, right after the firstdeployment, mechanical ventilator pressure suddenly increased, and a hugeamount of fresh bloody secretion was suctioned every 5 minutes. The activatedclotting time was 239 seconds. We performed a second deployment of a 9x10mm-sizedvascular plug quickly and quit the procedure by administering Protamine 20mg.Unfortunately, TEE showed similar amounts of PVL flow at the prosthetic MV.After theprocedure, large amounts of bleeding were confirmed in the left pulmonaryartery through a computerized tomography scan. The patient was positioned in a"left-down position" under complete paralysis and deep sedation.Using bronchoscopy, aspirated blood was toileted. After that, the patientinhaled nitric oxide gas to decrease pulmonary artery pressure. After 7 days ofICU care, the patient stabilized enough to transfer to the general ward withbilevel positive airway pressure.
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We tried toclose a severe PVL with a rocking mitral prosthesis in an elderly patient whohad a history of six previous OHS. We planned to perform the procedure becausewe judged that it is less invasive than OHS and has a lower peri-proceduralrisk. In this case, we could know that the peri-procedural risk is not lowerthan the peri-OP risk. Underestimating the peri-procedural riskdue to the less-invasiveness of the procedure should be thought of as anotherrisk factor of the procedure.