Navigating the Challenges: Amplatzar Vascular Plug II Dislodgement

Abstract

Background: Paravalvular leaks (PVL) are an infrequent but potentially serious complication of valve replacement procedures, occurring with both mechanical and prosthetic valves. While some patients with PVL remain asymptomatic, others may experience severe complications such as heart failure, significant hemolysis, and endocarditis. Case: This case report details a successful transcatheter mitral PVL closure in a 59-year-old patient with a history of multiple percutaneous coronary interventions (PCIs), heart failure with preserved ejection fraction (HFpEF), and severe mitral regurgitation, who underwent a mechanical mitral valve (On-X) replacement and coronary artery bypass grafting (CABG).Six months post-surgery, the patient was hospitalized with severe decompensated heart failure, florid pulmonary edema, and cardiogenic shock, requiring multiple pressors and high-flow oxygen. (TEE) 2D and 3D revealed a very large PVL encompassing almost 40% of the annulus. Due to the high risks associated with redo cardiac surgery, a percutaneous transcatheter closure was chosen. Initial attempts to deploy a 10mm AVP 2 plug failed, resulting in its dislodgement. Eventually, two AVP 2 plugs (12mm and 14mm) were successfully deployed simultaneously, significantly reducing the leak from the 12 to 4 o'clock position. The inferior leak was then closed with another wire and a 14mm AVP 2 plug. During the procedure, the patient experienced vascular plug embolization, initially lodging in the right atrium, then into the right ventricle, and finally the right pulmonary artery before being successfully retrieved. The retrieval of the dislodged plug involved multiple maneuvers and was ultimately successful using a Micra sheath, snare, and forceps. Post-procedure, the patient showed significant improvement, was weaned off pressors, and experienced marked symptom relief. Conclusion: This case highlights the importance of being prepared for potential complications, such as device embolization, during percutaneous procedures. This case is notable for involving both paravalvular leak closure and the retrieval of a free-floating device from the pulmonary artery.