Free-floating occluder device in the left atrium during paravalvular leak closure in a child: Nightmare in the cath lab

Paravalvular leak (PVL) is a complication that occurs in 5%–10% of patients after surgical mitral valve replacement. Reoperation may be necessary for a rare group of patients with heart failure or progressive hemolysis. Surgical repair has been considered a standard treatment method for a long time; however, the percutaneous route may be preferred owing to lower morbidity and mortality rates in high-risk patients. There are few experiences of percutaneous PVL closure in children. A 7-year-old-girl, who has been followed-up with dilated cardiomyopathy and left ventricle noncompaction cardiomyopathy (LVNC) diagnosis since she was 15-days old, underwent surgical mitral valve replacement due to severe mitral insufficiency. Further, 7 months after the operation, she was referred for severe mitral PVL that caused significant hemolysis requiring blood transfusion. Transesophageal echocardiography (TEE) revealed significant mitral PVL, moderate tricuspid valve insufficiency, LVNC, and reduced left ventricular contraction with a shortening fraction of 20% (Video 1). We decided to perform hybrid PVL closure because she was hemodynamically unstable and the operative risk was unacceptably high. After left anterior minithoracotomy, a 9 Fr introducer sheath was inserted into the left ventricular apex. The mean width of PVL measured by 3D-TEE was 16×6 mm (Fig. 1).