Coil Embolization of a Periprosthetic Mitral Valve Leak Associated With Severe Hemolytic Anemia
55-year-old man presented with severe fatigue, anorexia, and weight loss. His past medical history was significant for diabetes mellitus, severe mitral annulus calcification, aortic and mitral valve replacement, prosthetic mitral valve endocarditis complicated by periprosthetic mitral regurgitation, and repeat mitral valve replacement 2 months before admission.
Admission hemoglobin was 6 g/dL and additional laboratory evaluation was consistent with severe hemolytic anemia. A transesophageal echocardiogram (TEE) revealed a periprosthetic mitral valve leak that we believed to be the cause of the hemolytic anemia (Figure 1). During initial hospitalization, the patient remained transfusion dependent.
In view of his past history, we did not believe the patient to be a candidate for a third mitral valve replacement. Therefore, we decided to attempt coil embolization of the periprosthetic leak.
Using the transseptal approach, we crossed the perivalvular leak with a guidewire under TEE and fluoroscopic guidance (Figure 2). A 4F glide vertebral catheter (Boston Scientific) was then advanced over the wire into the ventricular apex. Using the 4F catheter, two 9-cm-long retrievable dumbbell coils, 5 mm diameter on each end and 2 mm diameter in the middle, were deployed across the leak. Postdeployment films demonstrated symmetric deployment of the coils across the mitral ring with approximately one half on either side (Figure 3).
The patient’s hemoglobin stabilized after the procedure, and his serum lactic dehydrogenase level decreased from a baseline of ≈4000 IU/L to ≈1400 IU/L. This was associated with a dramatic decrease in transfusion requirement (Figure 4). The international normalized ratio was maintained between 2 and 2.5, and the patient was discharged to his home in stable condition 5 days after the procedure. After discharge, his hemoglobin continued to remain stable, and at 9-month follow-up, there were no complications related to the procedure.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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