Acquired submitral aneurysm after mitral valve replacement is caused by weakness of the annular tissues induced by inflammation, scarring, and ischemia from surgical trauma. The asynchronous stretch of the annulus caused by the submitral aneurysm may cause recurrent paravalvular leaks. In patients with acquired submitral aneurysms and paravalvular leaks, ideal solution is a repeat surgery to address both the aneurysm and the leak. However, when patients are at high risk for repeat surgeries on cardiopulmonary bypass through sternotomy, transcatheter closure of these paravalvar leaks may offer an alternative solution. Four such procedures in three patients are detailed in this report.

Objectives: Ductal stents, right ventricular outflow tract stents, and aortopulmonary shunts are used to palliate newborns and infants with reduced pulmonary blood flow. Current long-term outcomes of these palliations from resource-restricted countries are unknown. Methods: This single-centre, retrospective, observational study analysed the technical success, immediate and late mortality, re-interventions, and length of palliation in infants ≤5 kg who underwent aortopulmonary shunts, ductal, and pulmonary outflow stents. Patients were grouped by their anatomy. Results: There were 69 infants who underwent one of the palliations. Technical success was 90% for aortopulmonary shunts (n = 10), 91% for pulmonary outflow stents (n = 11) and 100% for ductal stents (n = 48). Early mortality within 30 days in 12/69 patients was observed in 20% after shunts, 9% after pulmonary outflow stents, and 19% after ductal stents. Late mortality in 11 patients was seen in 20% after shunts, 18% after outflow stents, and 15% after ductal stents. Seven patients needed re-interventions; two following shunts, one following outflow stent, and four following ductal stents for hypoxia. Among the anatomical groups, 10/12 patients with pulmonary atresia, intact ventricular septum survived after valvotomy and ductal stenting. Survival to Glenn shunt after ductal stent for pulmonary atresia, intact ventricular septum and diminutive right ventricle was very low in two out of eight patients, but very good (100%) for other univentricular hearts. Among 35 patients with biventricular lesions, 22 survived to the next stage. Conclusions: Cyanotic infants, despite undergoing technically successful palliation had a high inter-stage mortality irrespective of the type of palliation. Duct stenting in univentricular hearts and in pulmonary atresia with an intact ventricular septum and adequate sized right ventricle tended to have low mortality and better long-term outcome. Completion of biventricular repair after palliation was achieved only in 63% of patients, reflecting unique challenges in developing countries despite advances in intensive care and interventions.

Hemodynamically significant large pulmonary embolism causes right ventricular dysfunction that stretches open the foramen ovale in the atrial septum. Paradoxical embolism is common in patients with right ventricular dysfunction. While anticoagulation and thrombolysis are considered the treatment of choice in pulmonary embolism, a large thrombus in transit across the patent foramen ovale carries a serious risk of systemic thromboembolism and warrants urgent surgery. The recent coronavirus disease 2019 (COVID-19) pandemic has led to a significant increase in the incidence of thromboembolic illnesses. A patient acutely presented with deep vein thrombosis, pulmonary embolism, large thrombus in transit across the foramen ovale along with elevation of multiple inflammatory biomarkers that were suggestive of a possible post-COVID sequelae. Images and management strategies are discussed in this report.