How should I treat a percutaneous posteromedial mitral periprosthetic paravalvular leak closure in a bioprosthesis with no radiopaque ring?

Paul T.L. Chiam, Yean-Teng Lim, et al

A 66-year-old male presented with worsening dyspnoea (NYHA Class III-IV), due to cardiac failure for several months. He had had a mitral valve replacement with a 27 mm Mosaic® bioprosthesis (Medtronic, Minneapolis, MN, USA) nine years before. Transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) revealed a left ventricular ejection fraction (LVEF) of 45% and severe mitral regurgitation (MR) due to a paravalvular leak (PVL). The defect was located posteromedially (4 o’clock position on the surgical view) and measured 3 mm at its width. The effective regurgitant orifice area was calculated to be 0.4 cm² and the regurgitation volume was 64 ml. The bioprosthetic valve leaflets were well visualised to be functioning normally and not thickened, with satisfactory haemodynamics (mean pressure gradient 7 mmHg). Coronary angiography showed no significant coronary artery disease. A left ventriculogram showed an MR jet located posteriorly and medially.