A 78-year-old woman with a long-standing history of rheumatic heart disease presented with complex multivalvular involvement, including MR, MS, AR and AS. She underwent two mitral valvuloplasties in her third and fourth decades of life and subsequently received combined surgical aortic valve replacement (AVR) and mitral valve replacement (MVR) in 2015, TAVR-in SAVR procedure in 2022 due to recurrent heart failure. However, in 2025, physical examination showed pitting edema and lung edema again.

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Aortogram: a paravalvular leakage noted between SAVR and TAVR valveHemodynamic study:- Pulmonary wedge pressure = 18 mmHg- Pulmonary artery pressure = 58/19 mmHg (mean 37 mmHg)- RV pressure = 71/5 mmHg- RA mean pressure = 9 mmHg- IVC pressure = 9 mmHg- Cardiac output (thermodilution): 3.73 L/min- PVR = 5 woods (408 Dynes.sec.cm-5)
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Under local anesthesia, the RFA was punctured, and a 6-Fr sheath was introduced. A 6-Fr pigtail catheter over a 0.035-inch J-tip wire was advanced into the ascending aorta, and an aortogram demonstrated a moderate PVL originating from the surgical valve ring and the aortomitral curtain.The pigtail catheter was replaced with a 6-Fr MPA2 catheter to delineate the anatomy of the transcatheter heart valves and PVL. A 6-Fr JL 3.5 catheter was then used for a nonselective left coronary angiogram, confirming the PVL adjacent to the aortic annulus. A Terumo guidewire was advanced through an Amplatz Left (AL1) catheter and successfully crossed the PVL into the left ventricle (LV).For device delivery, the LFA was also punctured, and a 6-Fr sheath was inserted. A pigtail catheter was placed in the ascending aorta to identify the left main ostium. Attempts to advance an AGA Amplatzer Vascular Plug (AVP) 10/7 mm through the PVL were made using multiple guiding systems, including AL and JR4 catheters, a 6-Fr Shuttle sheath, and a Superstiff 0.035-inch wire, but initial passage into the LV was unsuccessful.Balloon sizing was performed using a Boston Scientific Mustang balloon (4.0 mm × 20 mm × 75 cm) inflated to 4 atm. The 6-Fr sheath was exchanged for a 7-Fr sheath, and a 7-Fr Boston MP 90-cm guiding catheter was advanced into the LV. An AGA Amplatzer Vascular Plug 10/7 mm was successfully deployed across the PVL. Final aortography confirmed successful occlusion of the PVL.



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Traditionally, surgical repair has been the treatment of choice for clinically significant PVL. However, repeat surgery in elderly patients with multiple prior valve interventions carries substantial morbidity and mortality risks. In recent years, transcatheter PVL closure has emerged as a less invasive and effective alternative. The Amplatzer Vascular Plug is among the most commonly used devices for this purpose due to its flexibility, controlled deployment, and ability to conform to irregular defects.In this case, the patient’s PVL was successfully closed using an AVP 10/7 mm after multiple catheter exchanges and balloon sizing. Post-procedural imaging confirmed trivial residual PVL.