Secure the Plug: Ultimate Structural and Intervention Complex Paravalvular Leak Closure and Simultaneous Left Atrial Appendage Closure – A Case Report

<h2>Abstract</h2> Mitral paravalvular leak (PVL) is a challenging and potentially debilitating complication of prosthetic valve implantation, particularly when it occurs in the setting of prior closure attempts and complex anatomical alterations. We present the case of an 83-year-old woman with a history of robotic-assisted mitral valve repair, followed by bioprosthetic valve replacement, complicated by a PVL previously managed with 2 Amplatzer vascular plugs. She presented with worsening heart failure symptoms, and transesophageal echocardiography revealed a recurrent, severe PVL originating between the 2 existing plugs, adjacent to the left atrial appendage. Because of her elevated surgical risk, a transcatheter approach was pursued. The defect was successfully closed using a third Amplatzer vascular plug II, and given the anatomical proximity to the left atrial appendage and her history of atrial fibrillation, a simultaneous left atrial appendage occlusion with a 34-mm Amulet device was performed via a separate venous access. The procedure was completed without complication, and follow-up imaging demonstrated complete PVL closure with stable device positioning. This case highlights the feasibility of advanced percutaneous structural heart interventions in high-risk patients, even in anatomically complex settings with prior device interference.