LAUSR

A 65-years-old man presented with severe dyspnea due to mitral paravalvular leak (PVL). He previously underwent mitral repair with a complete 28 mm Carpentier-Edwards annuloplasty ring and had postoperative mitral valve endocarditis. Transesophageal echocardiogram (TEE) demonstrated severe mitral PVL originating from a medial defect (Figs. 1, 2). Our heart-team elected to perform percutaneous PVL closure due to his severe morbidities, 5.5% of STSscore. The procedure was performed using an antegrade approach. Following transseptal puncture along the posterior-septum, an 8.5-French, medium-curved Agilis catheter (St. Jude Medical, Fridley, MN, USA) was steered down anteriorly in the left atrium. An angled-tip, exchangedlength 0.035” Glidewire (Terumo, Somerset, NJ, USA) passed through a 6-French multipurpose (MP) guide catheter, was used to cross the defect using TEE and fluoroscopy (Fig. 3). After the MP was placed into the left ventricle (LV), the Agilis catheter was exchanged over a 260 cm Safari-wire (Boston Scientific, Marlborough, MA, USA) for 20-French Dryseal sheath (W. L. Gore, Flagstaff, AZ) due to the medial defect. Two 0.032′′ extra-stiff Amplatz wires were advanced though the MP catheter into the LV, followed by removal of the single MP and subsequent placement of two 6-French MP separately over each Amplatz wire (Figs. 4, 5). Next, we simultaneously deployed two 12-mm AVP-2 occluders (St. Jude Medical, Fridley, MN, USA). However, there was continued moderate PVL originating near the medial device, which was recaptured. We then exchanged this MP catheter over an 0.032 wire for a 6-French flexor sheath (Cook Medical, Bloomington, IN, USA) and deployed a 16-mm AVP-2 next to the previously placed plug (Figs. 6, 7, 8) with an 0.032′′ wire left in place as an anchor. Following