Case Reports

Transjugular Approach for Transcatheter Closure ofMitral Paraprosthetic Leak

George Joseph,* MD, DM and Viji Samuel Thomson, MD, DM

Transcatheter closure of mitral paraprosthetic leak (PPL) using femoral antegradetransseptal or retrograde approach is often unsuccessful when the involved part of themitral annulus is difficult to access or when the left atrium is large. We report the suc-cessful use of jugular venous approach to perform transseptal antegrade PPL closurein a 49-year-old male with mitral PPL located in the anteromedial part of the annulus.This technique could serve as a useful alternative in patients in whom transcatheterclosure of mitral PPL is technically difficult. VC 2009 Wiley-Liss, Inc.

Key words: heart valve prosthesis; jugular veins; atrial septum

INTRODUCTION

Mitral paraprosthetic leak (PPL) requiring reopera-tion is not an infrequent occurrence and has beenreported in 2.7–4.5% of patients who undergo mitralvalve replacement [1,2]. Surgery is the standard treat-ment for clinically significant mitral PPL, but is associ-ated with higher morbidity than the initial surgery,mortality of 6–22%, and increased risk of recurrenceof PPL [1–5]; transcatheter closure is an effective alter-native to surgery and is the preferred option in patientsin whom surgery is contraindicated or risky [6,7].Transcatheter closure of mitral PPL is most often per-formed using antegrade transseptal approach from thefemoral vein [6,8]; however, crossing the orifice of thePPL using this approach can be difficult and time-con-suming and is not always successful [6,7]; this has leadsome operators to use a retrograde aortic approachinstead [9,10], but this approach too has significantlimitations [8]. Antegrade transseptal approach fromthe right internal jugular vein offers a more directapproach to the mitral valve [11] and may facilitateaccess to parts of the mitral annulus that are difficultto approach using standard technique. We report use ofthe antegrade transseptal approach from the right inter-nal jugular vein to perform transcatheter closure of ananteromedially located mitral PPL.

CASE REPORT

A 49-year-old male presented with symptomatic PPL3 years after undergoing mitral valve replacement with

a bioprosthetic valve. Transesophageal echocardiogra-phy (Fig. 1) located a 6-mm-wide PPL in the antero-medial aspect of the mitral annulus, near the interatrialseptum and adjacent to the noncoronary aortic cusp.There was no evidence of prosthetic valve obstruction,instability, vegetations, or left atrial thrombus. Thepatient remained symptomatic despite medical therapy.He was considered a poor candidate for surgery inview of earlier protracted sternal infection, and so,transcatheter closure of the mitral PPL was planned;elective use of the jugular approach was favored inview of the anteromedial location of PPL, which isoften difficult to access [7].

PROCEDURE

The procedure was performed under general endo-tracheal anesthesia after obtaining written informed

Department of Cardiology, Christian Medical College, Vellore,India

Conflict of interest: Nothing to report.

*Correspondence to: George Joseph, MD, DM, Department of

Cardiology, Christian Medical College, Vellore 632004, India.

E-mail: cardio1@cmcvellore.ac.in

Received 22 May 2009; Revision accepted 1 June 2009

DOI 10.1002/ccd.22173

Published online 22 July 2009 in Wiley InterScience (www.

interscience.wiley.com)

VC 2009 Wiley-Liss, Inc.

Catheterization and Cardiovascular Interventions 74:971–974 (2009)

consent. Transesophageal echocardiographic guidancewas utilized. Transseptal puncture was performed usingright internal jugular vein approach [11] and a pediatricBrockenbrough needle (USCI, Bard) introducedthrough a short 5F catheter, after which the 5F catheterwas advanced over the needle into the left atrium. A9F 30-cm-long sheath was inserted into the left atriumover a wire. Retrograde left ventriculography (Fig. 2A)delineated the mitral PPL. A 6F right Judkins angio-graphic catheter and 0.03500 hydrophilic wire (Terumo,Meditech, Watertown, MA) were used to traverse thePPL from its left atrial aspect. The wire was manipu-lated into the aorta, and the catheter was advancedover it (Fig. 2B). The 9F sheath was advanced withoutdifficulty across the PPL into the left ventricle; accessthrough the PPL was secured by leaving an indwelling0.01800 Roadrunner wire (Cook) in the left ventricle. A10/8 mm Amplatzer-type patent ductus arteriosusoccluder (Shanghai Shape Memory Alloy Company,China) was attached to a delivery cable and advancedthrough the 9F sheath alongside the indwelling 0.01800wire and deployed across the defect using fluoroscopic,angiographic, and echocardiographic guidance (Fig.2C). Postdeployment left ventriculogram showed com-plete closure of the PPL (Fig. 2D). There was no evi-dence of prosthetic mitral valve dysfunction after thedevice was released. All sheaths were removed imme-diately after the procedure, and hemostasis wasachieved by manual compression. The total proceduretime was 89 min. The patient has completed 21 monthsof follow-up after the procedure and has been asymp-tomatic with normal effort tolerance. Serial echocardio-

grams have revealed stable device position, no PPL(Fig. 3), and normal prosthetic valve function.

DISCUSSION

Crossing a mitral PPL is an essential prerequisite fortranscatheter closure; unsuccessful procedures areinvariably due to failure to cross the PPL with theguide or sheath used to deliver the closure device. Pate[6] reported failure to cross in two of nine patients(22%) with mitral PPL; Cortes [7] reported failure tocross in 10 of 27 patients (38%) and noted that failurerate was lowest for posterior PPL 2/12 (17%) andhigher in PPL located elsewhere 8/15 (53%), especiallyanterior PPL 2/3 (67%).

The antegrade transseptal approach is generally pre-ferred for crossing a mitral PPL; however, the jet of re-gurgitation may deflect the catheter/wire away fromthe orifice of the leak [9]. Also, mitral PPLs locatedanteromedially are often difficult to access and mayrequire septal puncture at unconventional points andspecially shaped sheaths and catheters to approachthem; the shape of catheter that directs the wire towardthe PPL may be inappropriate for advancement of cath-eter across the PPL; an exteriorized arteriovenous wireloop may be required for sufficient support to pass alarge-bore delivery sheath through a tight defect—ex-cessive tension on this wire could result in vascularinjury or damage to cardiac structures; the presence ofa large left atrium compounds many of these technicalproblems [7,8].

Fig. 1. Transesophageal echocardiography at mid-esophageal level in (A) four-chamber viewand (B) left ventricular outflow view, showing mitral paraprosthetic leak (arrow). LA, leftatrium; LV, left ventricle; RA, right atrium; RV, right ventricle; Ao, aorta.

972 Joseph et al.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

Fig. 3. Follow-up transthoracic echocardiography in parasternal long-axis view: (A) Systolicframe showing absence of regurgitation into the left atrium; (B) diastolic frame showingnonturbulent antegrade flow through prosthetic mitral valve. LA, left atrium; LV, left ventricle;Ao, aorta.

Fig. 2. (A) Left ventriculogram in right anterior oblique projection showing regurgitant jet(arrows) of mitral paraprosthetic leak (PPL) in the left atrium. (B) Catheter course from theleft atrium, through the PPL, looping around in the left ventricle and entering the aorta. (C)Deployment of closure device in the PPL using transjugular approach. (D) Postdeploymentleft ventriculogram showing absence of regurgitation into the left atrium through the PPL.

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An alternate approach is to cross mitral PPL retro-grade from the left ventricle; high-velocity regurgitantjets may assist in wire passage [8,9]. However, thisapproach is hampered by the irregular ventricular walls,and wire passage through trabeculae or chordae may notbe recognized until the occluder delivery sheath cannotbe advanced; ventricular ectopy and catheter stabilitymay be problematic and the tight bend may not allowdevice delivery [8]. A modification of the retrogradeapproach is to snare the retrograde wire in the leftatrium through a transseptal sheath and exteriorize itthrough the femoral vein to allow completion of the pro-cedure in an antegrade manner [9]; however, snaring awire in a large left atrium may be difficult.

The jugular venous approach to transseptal antegradePPL closure offers two distinct advantages. First, asexemplified by the lie of the catheter/wire in Fig. 2B/2C, the jugular transseptal technique provides a directand proximate approach to the mitral annulus, especiallyits medial and anterior aspects, which may be difficultto reach by other approaches. Second, a large left atriumis not disadvantageous in the jugular transseptal tech-nique; in fact, a large left atrium with bulge of the atrialseptum toward the right facilitates transjugular septalpuncture by reducing the tendency of the transseptalneedle to slip down the atrial septum [12]. Routine useof the jugular approach for antegrade PPL closure mayimprove success rates in patients with large left atriumand/or anteromedially located PPL, which are situationswhere other approaches have been difficult or unsuc-cessful. Transjugular left atrial access has been shownto be useful in balloon mitral valvuloplasty proceduresin patients with cardiac anatomic distortion [12] andcould potentially find application in procedures such asradiofrequency ablation of left-sided bypass tracts andtranscatheter mitral valve repair.

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