DASH Closure: A Dual Access Strategy for Hemodynamic Closure of Mitral Paravalvular Leaks

Paravalvular leaks (PVLs) are common complications following prosthetic valve implantation, significantly impacting patient outcomes due to associated heart failure and hemolysis. While percutaneous closure is a recognized alternative to surgery, challenging anatomies and multiple leaks can be difficult to manage with traditional single-access techniques.

We present a case of a patient with a mechanical mitral prosthesis and two clinically significant mitral PVLs-one anterior and one posterolateral. The patient presented with symptoms of heart failure and was experiencing transfusion-dependent hemolytic anemia. To address the PVLs, we employed a dual-access strategy. We used a standard transseptal anterograde approach to close the anterior PVL and a retrograde transfemoral arterial approach to close the larger posterolateral defect. Two dedicated PVLs occlude devices were successfully implanted without impacting the motion of the prosthetic leaflets. The total procedural time was 95 min, comprising 38 min of fluoroscopy and a total iodinated contrast volume of 120 mL. Fortunately, no periprocedural complications occurred. Upon follow-up, the patient demonstrated sustained clinical improvement, with resolution of hemolysis and only a trivial residual mitral PVL observed on echocardiography.

The DASH approach combines two access routes to overcome the limitations of traditional single-access methods. By using the Venturi effect, we simplify the procedure, improve device maneuverability, and increase success rates, even in complex cases.

In selected patients with multiple, anatomically complex mitral PVLs-particularly when catheter alignment, stability, or prosthetic leaflet interaction limits a single-access approach, a planned dual-access strategy may represent a complementary technical option to facilitate safe device delivery. Larger series and longer follow-up are needed to define the indications, safety profile, and durability of the DASH approach.