Peratrial Device Closure of Different Locations of Mitral Paravalvular Leaks

The current approaches of transcatheter closure of mitral paravalvular leak (MPVL) have different drawbacks. The challenges come from transseptal puncture, accessing the MPVL site, and the absence of dedicated delivery systems. This study introduces a novel peratrial approach for device closure of different locations of MPVLs using a probe-assisted delivery system under three-dimensional transesophageal echocardiography.

A 4.0-cm minithoracotomy incision was made in the fourth right interspaces. The right atrium and the interatrial septum were punctured and dilated, followed by a guidewire passing through the septum. A specially designed J-shaped bendable hollow probe was advanced into the left atrium. The steerable probe was adjusted to cross the MPVL and introduced a stiff guidewire into the left ventricle. A 7F short delivery sheath was advanced over the wire through the MPVL into the left ventricle. A proper-sized muscular septal occluder was then selected and deployed.

Transesophageal echocardiography revealed complete occlusion in 7 of 8 patients after a follow-up of 6 months to 4 years. Mild residual paravalvular regurgitation occurred in an early patient. In 2 patients with a crescent-shaped MPVL, two guidewires were advanced into the left ventricle across the leak, and double devices were deployed sequentially. All patients' symptoms improved by at least one New York Heart Association functional class.

The peratrial technique can access and close MPVLs at different locations through a right minithoracotomy approach. This technique has the advantages of easy transseptal puncture, easy access to the MPVL site, and no exposure to radiation.