Tricuspid perivalvular leak closure through the open cells of Sapien 3 transcatheter heart valve

off-label 29mm Edwards Sapien 3 (S3) Transcatheter Heart Valve (THV). Immediate post valve deployment, mild Perivalvular Leak (PVL) was noticed at the septal aspect (area of incomplete annuloplasty ring). Eighteen months later, patient presented with recurrent right heart failure and paracentesis due to severe tricuspid PVL (Figure 1A-C, Video 1). Percutaneous PVL closure under general anesthesia, Trans-esophageal Echocardiography (TEE) was performed. Via femoral venous access, defect was easily crossed with Agilis steerable sheath, multipurpose catheter and 0.035” glide wire. Despite recurrent attempts, wire came through the PVL but then traversed through open cells of S3 into the right ventricle (Figure 2A), confirmed with Armada 6mm balloon waist at the S3 cage (Figure 2B) (despite inflating 28mm Z med balloon inside S3 cage, Figure 2C). We decided to partially deploy the plug and assess valve function. Using 7.5F Asahi Eaucath multipurpose guide, a 12mm AmplatzerTM Vascular plug II (AVP II) was advanced through the defect. The ventricular disc was opened inside the S3 cage while body in the PVL defect (outside the S3 cage) and atrial disc on the atrial side of PVL (Figure 3A-B). With S3 function unaffected, no central leak and minimal gradient, PVL reduced to mild severity (Figure 4A-D, Video 2); the AVP II was successfully deployed (Figure 5). At 3-month follow up, there was an excellent symptomatic improvement (NYHA functional class I), with no heart failure re-hospitalization or paracentesis. Deployment of plug disc inside the valve frame is not recommended due to fear of interference with leaflet function and possible injury in long term. There was no immediate issue with the valve function in this case (due to space between the leaflet and frame of S3 and depends on size of plug used). Valve-in-Valve (S3-in-S3) would have certainly sealed all open cells treating this PVL but is more expensive option.