Prison Break: Extraction of a Plug Jailed Between Two Mechanical Valves

Paravalvular leak (PVL) occurs in up to 17% of prosthetic valve replacements, mainly in the mitral position. Surgery is the gold standard but carries high morbidity in patients with a history of previous sternotomies. Transcatheter closure of PVL offers a minimally invasive alternative with a very high success rate. Device migration, while uncommon, can be catastrophic when impinging on mechanical prosthetic valve performance. We report the case of a 37-year-old woman with prior mechanical mitral and aortic valve replacements, complicated by recurrent heart failure due to a mitral PVL resulting from suture dehiscence. Initial transcatheter closure with two Amplatzer Vascular Plug III devices achieved a substantial reduction of regurgitation. Four months later, she presented with acute pulmonary edema caused by migration of one device into the left ventricular outflow tract, intermittently obstructing a mechanical aortic valve leaflet. Given her prohibitive surgical risk, percutaneous retrieval was undertaken, followed by immediate re-closure of the PVL during the same procedure, successfully restoring valve function and hemodynamic stability. This case illustrates the complexity of late PVL management after mechanical mitral valve replacement and highlights the potential risk of device migration. While surgery remains the gold standard, percutaneous intervention represents the only viable option in patients at prohibitive surgical risk. To our knowledge, this is the first reported case of successful percutaneous retrieval of an embolized device through a mechanical prosthesis, followed by re-closure of the PVL within the same procedure. This experience underscores the feasibility of advanced bailout strategies in carefully selected patients.