A Novel Technique for Percutaneous Mitral Paravalvular Leak Closure: LBBAP Lead Assisted Ventricular Septal Way.

BACKGROUND

Percutaneous mitral paravalvular leak (PVL) closure in patients with double mechanical valves presents substantial technical challenges when conventional transseptal antegrade approaches fail. Transapical puncture, while an alternative, carries significant risks including hemothorax and coronary injury. Safe and reliable left ventricular (LV) access without high-risk transapical puncture remains a critical unmet need in complex structural heart interventions.

METHODS

A 69-year-old woman with mechanical mitral and aortic valve replacements and persistent PVL despite prior percutaneous closure presented with recurrent heart failure symptoms. Transesophageal echocardiography demonstrated two moderate-to-severe PVL jets at the 7 o'clock position surrounding the previous occluder device. A Left Bundle Branch Area Pacing (LBBAP) delivery system was advanced from the left subclavian vein to create a controlled interventricular septal puncture under continuous unipolar pacing and electrocardiographic monitoring.

RESULTS

The LBBAP-assisted interventricular septal crossing established a stable transventricular tract from right to left ventricle, enabling advancement of an 8.5 Fr steerable sheath. A separate transseptal puncture provided left atrial access. A veno-venous loop was created using a snare technique, facilitating deployment of two Amplatzer vascular plugs (8 × 7 mm AVP-II and 12 × 5 mm AVP-III) across the mitral PVL defects under transesophageal echocardiographic and fluoroscopic guidance. At follow-up, she remained asymptomatic, with no residual ventricular septal flow on imaging.

CONCLUSIONS

This first reported case of LBBAP-assisted interventricular septal access for mitral PVL closure demonstrates feasibility and safety as an alternative when conventional approaches are not viable. This technique avoids transapical puncture risks and may expand therapeutic options for anatomically challenging structural heart interventions, particularly in patients with double mechanical valves (NCT07129122).