Sixty-six-year-old male patient with a past medical history of mitral and aortic valve replacement in 1983. Back in 2005 he underwent a new aortic valve replacement due to prosthetic valve dysfunction. In 2018, also due to prosthetic valve dysfunction, a new mitral valve replacement was performed with a size 27 Bicarbon Fitline heart valve (Sorin Group, Italy).

Three months later the patient was hospitalized with functional class III-IV heart failure according to the New York Heart Association (NYHA) and hemolytic anemia with multiple mitral paravalvular leaks quantified as severe regurgitation. In a single medical-surgical session it was decided to perform percutaneous treatment due to the patient’s high surgical risk. The percutaneous closure of the leaks was performed using 7 Amplatzer Vascular Plug III devices (figure 1E) that resulted in minimal residual leaks.

In 2019 the patient presented with NYHA functional class III-IV and hemolytic anemia back again. The 3D echocardiogram performed revealed the presence of 2 severe mitral paravalvular leaks (figure 2A,B) (video 1 of the supplementary data). Percutaneous approach was attempted. An antegrade venoarterial circuit via transseptal puncture was built using a 0.035 in hydrophilic guidewire (figure 1A,B) (videos 2 and 3 of the supplementary data), 2 12/5 mm Amplatzer Vascular Plug III devices were implanted (figure 1C) (videos 4 and 5 of the supplementary data), and 9 devices of the same type surrounding the prosthetic circumference (figure 1D and figure 2D) (video 6 of the supplementary data). The procedure was completed uneventfully. The transesophageal echocardiography performed during the procedure confirmed the reduction of mitral paravalvular leaks now quantified as mild regurgitation (figure 2C) (video 7 of the supplementary data). Disease progression was good, and the patient was discharged with NYHA functional class II-III, corrected anemia (hemoglobin of 12 g/dL), and outpatient follow-up.

Figure 1.

Figure 2.

CONFLICTS OF INTEREST

I. Cruz Gónzalez is proctor for Abbott.

An 80-year-old male with permanent atrial fibrillation (informed consent obtained) underwent a percutaneous procedure to close the left atrial appendage (LAA). He had required repeated admissions for severe anemia and chronic gastrointestinal bleedings while on different antithrombotic regimens (aspirin alone, clopidogrel alone, apixaban). He had a CHADS-VASC₂ score of 6 and a HAS-BLED score of 4. A transesophageal echocardiography (TEE) performed revealed the presence of Windsock morphology and no thrombus in the LAA. The diameters of the landing zone were between 23 mm and 25 mm (figure 1).

Figure 1.

A 28-mm Amulet device was chosen to perform the procedure. A 14-Fr introducer sheath was advanced into the left atrium and, after a selective angiography, the device was deployed inside the LAA in a regular fashion. The first deployment did not achieve a good position (partially outside the appendage) and the device had to be recaptured. A second attempt was made with significant counterclockwise rotation of the sheath that achieved a peculiar “twisted” deployment of the body of the device (figure 2) whose distal part was actually deployed inside the appendage. It was carefully recaptured and after discarding pericardial effusion, it was re-implanted in a good position this time with no further need to change the device (figure 3). A transthoracic echocardiography performed the next day revealed no pericardial effusion. The TEE performed 1 month later revealed no leaks or thrombi on the device either.

Figure 2.

Figure 3.

The immediate complications described with LAA occluding devices are embolization, incomplete closure with residual leaks or the development of pericardial effusion and cardiac tamponade. Twisted malappositions are actually rare and could be predictors of short-term complications.

FUNDING

No funding source related to he manuscript.

AUTHORS' CONTRIBUTION

F. Hernández and E. Lázaro, procedure performance; all authors contributed in the drafting and revision of the manuscript.

CONFLICTS OF INTEREST

F. Hernández Hernández is a proctor for Abbott on issues concerning left atrial appendage occlusions.

Two-month baby recently treated with closure of perimembranous interventricular communication with congestive clinical signs in the postoperative period and echocardiographic suspicion of possible right coronary artery-to-right ventricle fistula confirmed on the cardiac computed tomography and catheterization with nonselective coronary angiography. Parents' informed consent was obtained for the dissemination of the case. A large coronary fistula—eligible for percutaneous closure—can be seen exiting the right coronary artery marginal branch and entering the right ventricular cavity with great dilatation of the right coronary artery proximal segment (figure 1). A 4-Fr carrier catheter is inserted into the right coronary artery and a guidewire is advanced towards the right ventricle. Assisted by an angioplasty balloon, the carrier catheter is then advanced towards the fistula proximal zone where eventually a 4 × 6 Amplatzer Vascular Plug (AVP4) device (Abbott, United States) is delivered resulting in the total occlusion of the defect with no interference with the distal right coronary artery (figure 2).

Figure 1.

Figure 2.

Seventy-year-old male patient with an incidental finding on the transthoracic and transesophageal echocardiography of a large mass in the right atrium with abundant vascular component. Patient' informed consent was obtained for the dissemination of the case. The cardiac CT performed confirmed the finding of an arteriovenous malformation. The coronary angiography performed shows afference from the mid-right coronary artery towards the atrial mass and percutaneous closure is decided. The closure is performed by advancing a microcatheter towards the afferent branch mid-section and protecting the mid-right coronary artery through the inflation of the angioplasty balloon. Ten Hilal Coils (Cook Medical, United States) are delivered with good results and complete closure of the defect (figure 3).

Figure 3.

FUNDING

No funding to declare.

AUTHORS' CONTRIBUTION

All authors have contributed to the elaboration, drafting and revision of the manuscript.

CONFLICTS OF INTEREST

None declared.