Images from a 74-year-old woman with a St. Jude mechanical mitral prosthesis. There is a large superolateral perimitral leak. (A) Transeptal puncture and subsequent placement of the 8.5-F Agilis sheath (St. Jude Medical, St. Paul, Minnesota) directing the extra stiff angled glidewire (Terumo, Elkton, Maryland) through the perimitral leak into the left ventricle. (B) Initial delivery of 14-mm Amplatz Vascular Plug II (AVPII) (AGA Medical Inc.) with obstruction of the lower disc of the prosthetic valve. The upper leaflet is open (arrowhead). (C) With some additional traction on the AVPII, the distal disc become slightly bulbous and is pulled more into the defect. (D) After release, the mechanical valve leaflets remain free and the defect is effectively plugged with the central body of the device. The arrows indicate the proximal and distal discs of the device, and the arrowheads indicate the mechanical prosthesis leaflets in the open position. The distal portion remained bulbous but reduced the insufficiency to a minimal amount.

Images from a 62-year-old man with mechanical mitral prosthesis and a large paravalvular leak. (A) The intraprocedural transesophageal (TEE) demonstrated this large superolateral defect and a large regurgitant jet with color flow imaging. (B) A slit-like defect could be observed with live 3-dimensional (3D) TEE imaging (Online Video 1). (C) A large 10-mm muscular ventricular septal defect (VSD) occluder was placed; this initially seemed to effectively reduce the degree of shunt and appeared to be well positioned by fluoroscopic images with flat, well-positioned ventricular and atrial discs. (D) Subsequently, a large residual regurgitant volume was noted with persistent hemolysis. (E) Surgical exploration demonstrated a well positioned device but a significant extension of a large slit-like defect just next to the device. (F) Upon removal of the VSD occluder the extent of this oval slit-like defect was evident. (G) Once removed, the device appeared to be compressed or stretched (arrows) centrally but otherwise normal in shape. LA = left atrium; LV = left ventricle.

Images from a 79-year-old woman with mitral tissue bioprosthesis and a large superior paravalvular leak associated with severe hemolytic anemia. (A) The intraprocedural transesophageal echocardiogram demonstrated a large superomedial regurgitant jet consistent with severe regurgitation (Online Video 2). (B) A 12-mm muscular ventricular septal defect occluder was successfully positioned in the tract of the long defect, but in order to place the proximal atrial disc on the LA side of the prosthesis the device became severely elongated and produced a bulbous configuration at the distal ventricular disc (arrows). The central body is stretched thin (arrowhead). (C and D) Subsequent 3-dimensional transesophageal study demonstrated a well-positioned LA disc but persistent bulbous ventricular disc and moderate residual regurgitation about and through the device (D) with persistent hemolytic anemia (Online Video 3). A = anterior; S = superior; other abbreviations as in Figure 2.

Images from a 63-year-old-woman with 25-mm Biocor tissue prosthesis and associated large inferomedial paravalvular leak. The patient also had hemolytic anemia. In addition, there was a 21-mm St. Jude mechanical prosthesis in the aortic position. (A) There is a severe inferomedial regurgitant jet observed with transesophageal imaging. (B) A full-volume color flow 3D image demonstrated the large inferomedial jet and a smaller associated tiny superomedial lesion (Online Video 4). Online Video 5 shows the same color flow as visualized from the ventricular aspect. (C) The glidewire was then repositioned correctly through the large inferomedial lesion demonstrated by a live 3D image (Online Video 6) and a 10-mm muscular ventricular septal defect (MVSD) occluder was successfully implanted in the paravalvular tract to nearly completely occlude the defect. (D) A minimal residual shunt was demonstrated on this full-volume 3D color flow image (arrow) and the hemolysis subsequently resolved (Online Video 7). Abbreviations as in Figure 2.

Images from a 86-year-old woman with a large superolateral paravalvular leak over a 31-mm St. Jude Porcine bioprosthesis. (A) Initial intraprocedural TEE image demonstrating the larger superolateral regurgitant jet. (B) 3D full-volume image of LA view of 12-mm AVPII in the paravalvular defect. (C) Right anterior oblique fluoroscopic view of the implanted AVPII. Note the long tract of the paravalvular leak. Both ventricular and atrial disc of the AVPII are well positioned and flat, while the central body of the device occludes the defect tract and is compressed within it. (D) TEE image demonstrating trivial residual paravalvular regurgitation about the device. The patient has continued to improve after device closure. Abbreviations as in Figures 1 and 2.

Images from a 78-year-old woman with aortic and mitral tissue prostheses. There were 2 lateral perimitral lesions with moderate regurgitation and associated hemolytic anemia. The patient initially had placement of a 12-mm AVPII in the inferolateral defect. Because of persistent hemolysis, she returned for closure of the second defect. (A) TEE image demonstrating with color flow image a large residual regurgitant jet at the superolateral margin of the mitral prosthesis. (B) Live 3D TEE image demonstrating a glidewire (arrowhead) placed in the residual defect (Online Video 8). The image clearly shows an oblong shaped defect with a wide atrial orifice (arrow) (Online Video 9). (C) Right anterior oblique fluoroscopic image demonstrating placement of a second 12-mm AVPII in the superior defect. Note both discs (arrows) are well deployed and flat on the atrial and ventricular sides while the central body (arrowheads) occupies the oval-shaped central tract. (D) Post-placement TEE and 3D images show well positioned devices (arrows) and the regurgitant jet was reduced to a trivial leak. L = left; VP = vascular plug; other abbreviations as in Figures 1, 2, and 3.