The technical challenges and feasibility of complex paravalvular leak repair are discussed through a case based example. A frail septogenarian presented with dyspnea due to severe paravalvular mitral regurgitation. She had severe scoliosis and cardiac cachexia. There were problems with hemolysis necessitating repeated blood transfusion. Logistic EuroSCORE was 36.4% and STS score 15.5% for mortality, 53.2% morbidity or mortality. NYHA class was IV with progressive symptoms necessitating prolonged hospitalization. The surgical opinion was that redo surgery would confer excessive risk and she was declined for further open surgery. Amplatzer transcatheter paravalvular leak repair was performed using multiple devices. Predischarge there was a marked improvement in symptoms, from NYHA IV (immobile and bedbound) to NYHA II. The patient was discharged improved but remained frail. She continued to have problems with hemolysis, although the frequency of blood transfusions required declined significantly. At 3 months, the LV cavity dimension decreased from 47 mm to 38 mm, still with preserved LV systolic function. There was trace paravalvular MR, which was sustained at 6 months. Complex paravalvular leaks can be repaired with Amplatzer devices by transcatheter approach in very high risk patients. Several tools may be required to overcome anatomical challenges. A partially successful or unsuccessful initial procedure may yield an excellent final result through judicious staging and perseverance.
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