History
69-year-old woman No known drug allergies High blood pressure (HBP) Hypercholesterolemia Bronchial asthma and pneumonia in 2009
Chronic atrophic gastritis and chronic hepatitis C virus (HCV) liver disease
Chondrocalcinosis Calcifying tendinitis of the right shoulder
Osteoporosis Hyperparathyroidism with parathyroidectomy in 2001
Bilateral sensorineural hearing loss Dry eye syndrome

Cardiological history
In 1978 he underwent mitral and aortic valve replacement with biological prostheses. In 1990, both prostheses malfunctioned, so a new replacement with two mechanical prostheses was performed. The aortic prosthesis was implanted at the level of the coronary ostium, so it was necessary to perform two aortocoronary grafts (saphenous vein to the anterior interventricular and right coronary artery). In 2002 he was admitted for heart failure and haemolytic anaemia related to late periprosthetic dehiscence, so a new mitral valve replacement was performed with another mechanical prosthesis and new aortocoronary grafts (saphenous vein to the middle anterior descending artery and to the right coronary artery). In 2003, DDD pacemaker implantation was performed due to symptomatic sinus node disease with paroxysmal atrial fibrillation. Cardiologically asymptomatic until 2014, when she was admitted several times for heart failure, the last one in August 2014.

Current illness
Patient admitted for a new episode of heart failure in December 2014. A control transthoracic echocardiogram (TTE) was performed, followed by a transesophageal echocardiogram (TEE) which confirmed the presence of two mitral periprosthetic leaks (one septal and one posterior).
Taking into account the patient's morbidity and the high surgical risk, the patient was scheduled for percutaneous leak closure. This procedure was performed on 08/01/2015 under general anaesthesia and with transesophageal echocardiography control in the haemodynamics room.
Initial access was via the right femoral vein and, after transseptal puncture, an attempt was made to cross the posterior mitral leak (as it was the largest) in an antegrade manner, without success. Therefore, it was decided to puncture the left femoral artery and cross the mechanical aortic prosthesis with a guide and a catheter with good haemodynamic tolerance. The posterior leak is crossed and the guidewire is captured in the left atrium (LA) with a loop, externalising via the right femoral vein, thus creating an arteriovenous (AV) shunt. The size of the defect by 3D TEE is 10x4 mm, so a 10x5mm Vascular Plug device is chosen for closure. A release sheath is advanced from the right femoral vein through the defect into the left ventricle (LV) and the device is released from the LV to the LA with good placement and effective closure of the defect (video 3 and figure 1). The procedure is completed and the left femoral artery puncture is closed with good results. The patient was extubated in the ward and transferred to the coronary unit for evolutionary control in good clinical condition.

Physical examination
BP: 110/48 mmHg. HR: 107 bpm. Sat.02: 100% (Reservoir at 100%). Afebrile. Conscious and oriented, good skin and mucous membrane colouring, good peripheral perfusion, eupneic at rest. Head and neck: no jugular ingurgitation. Cardiac auscultation: rhythmic, no murmurs. Pulmonary auscultation: preserved vesicular murmur.
Abdomen: soft, depressible, not painful on palpation, no signs of peritoneal irritation, no masses or megaliths. Sounds present. Lower extremities: no oedema. Pedial pulses present and symmetrical. No haematoma in puncture sites. Sensibility and mobility preserved.

COMPLEMENTARY TESTS
Preoperative TTE: LV neither dilated nor hypertrophic, with good global systolic function, apical aneurysm. The mechanical mitral prosthesis has a slight systolic Doppler signal. Aortic root not dilated. Mechanical aortic prosthesis with mild regurgitation and maximum gradient of 40 mmHg. Moderately dilated LA. Dilated right chambers. Right ventricle (RV) with moderate dysfunction. Moderate tricuspid regurgitation with RV-RA gradient of 65 mmHg. Estimated PsAP of 80 mmHg. RV pacing lead. No pericardial effusion. Preoperative TEE: mitral prosthesis with two periprosthetic leaks, one septal and one posterior, both moderate.

EVOLUTION
In subsequent outpatient controls, the patient reported feeling better, with improvement in her functional capacity. She has lost weight. In the subsequent control TTE she presented mild periprosthetic mitral insufficiency.

DIAGNOSIS
Leaks or periprosthetic mitral dehiscence.
