A 42-year-old man with a history of ventricular septal defect (VSD) repair and mechanical aortic valve (AV) replacement 2 years ago. Echocardiography showed a 4.9mm ventricular residual shunt (RS) adjacent to aortic valve, and 3D reconstruction based on CT scan clearly showed the RS and an ambiguous paravalvular leak (PVL).

Because hemodynamic instability occurred when passing through the AV with even a 5 Fr catheter, we decided to pass the catheter into the left ventricle (LV) via the PVL for exploring the defects. A guidewirewas successfully inserted to LV through the PVL, and the location and size of the RS were finally determined. With the help of an artificially shaped pigtail catheter, the guidewire was eventually introduced from LV to right ventricle through the RS, and was used to make an arteriovenous loop. A long this loop, an 8Fr delivery sheath was advanced from venous access to the LV. An optimal symmetrical 7mm VSD occluder was then deployed, successfully sealing the RS.

All available delivery sheaths were too short to occlude the PVL via a femoral artery. So a brachial artery was used to occlude the PVL by ADO-II.

An echocardiography post the procedure revealed that two occluders respectively placed for VSD residual shunt and PVL were well seated without peri-device flow, and that the mechanical AV functioned normal. Herein, we describe the first case of simultaneous percutaneous closure of mechanical aortic PVL and VSD residual shunt.

Dr. Han Yu , Central China Hospital, Fuwai Hospital, Chinese Academy of Medical Sciences reported an innovative case in European Heart Journal: the residual leakage of the ventricular septal defect was sealed with a closure device that was passed into left ventricle through the aortic valve leakage, and closure of the aortic valve leakage was subsequently completed through the brachial artery. Both the procedure for sealing the residual leakage of the ventricular septal defect and the aortic valve leakage were completed at the same time.

Dr. Han Yu made a bold innovation to complete the left ventricle ventriculogram with utilizing the periaortic valve leak, defined the location and size of the residual shunt of the ventricular septal defect, and established the route to successfully complete the occluding of the residual leakage through the periaortic valve leak. Another difficulty was that none of the existing delivery sheaths is long enough to complete the closure of the aortic valve from the femoral artery. Again, Dr Han Yu intelligently used the brachial artery and smoothly completed the closure of the aortic valve leakage.

In the report, this novel approach in Central China Hospital, Fuwai Hospital, Chinese Academy of Medical Sciences provides a new idea for simultaneous repair of complicated ventricular septal defect and periaortic valve leakage with the minimally invasive interventional method in clinical practice.

Han Y, Sun Z, Fan T. Simultaneous percutaneous closure of aortic paravalvular leak and residual shunt of ventricular septal defect. Eur Heart J. 2023 Jan 12:ehac804. doi: 10.1093/eurheartj/ehac804.