Around and Through: Successful Mitral Paravalvular Leakage Closure Using Both Anterograde and Retrograde Approaches

Paravalvular leak (PVL) is a recognized complication after surgical mitral valve replacement and may cause heart failure, pulmonary hypertension, or hemolysis when moderate or severe. Although redo surgery is the definitive treatment, it carries substantial risk in elderly patients or those with multiple prior cardiac surgeries. Transcatheter PVL closure has therefore emerged as a valuable alternative, albeit with significant technical challenges in the mitral position. We describe the case of a 78-year-old woman with a history of two prior mitral valve replacements using bioprosthetic valves, who presented with progressive dyspnea. Echocardiography demonstrated structural valve degeneration of the mitral bioprosthesis with a large postero-medial mitral PVL causing severe regurgitation. Given the prohibitive surgical risk, percutaneous PVL closure was selected following Heart Team discussion. The procedure was performed under general anesthesia with transesophageal echocardiography and fluoroscopic guidance. An initial antegrade transseptal approach enabled deployment of the first occluder device, but significant residual regurgitation persisted. A second device could not be adequately positioned antegrade and was therefore deployed using a retrograde transaortic approach, which provided improved coaxial alignment. Final imaging showed mild residual regurgitation and a significant reduction in transmitral gradient. The patient had an uneventful recovery with rapid symptomatic improvement and remained clinically stable at 1-month follow-up. This case highlights the feasibility and effectiveness of a hybrid antegrade-retrograde strategy for complex mitral PVL closure and underscores the importance of procedural flexibility and multimodality imaging in achieving optimal outcomes in high-risk patients.