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Figure 2. This 64-year-old woman underwent percutaneous repair of a perivalvular leak of her St. Jude mechanical mitral prosthesis. An arteriovenous rail was constructed to deliver the septal occluder. Top left, Transesophageal echocardiography shows the perivalvular regurgitant jet (arrowhead). Top right, A snare is placed across the aortic valve into the left ventricle. Middle left and right, A guidewire is advanced from the left atrium through the defect into the left ventricle, where it is snared to create the arteriovenous rail. The arteriovenous rail provides strong support for delivering devices across the perivalvular leak. Bottom left, A septal occluder has been deployed. Bottom right, Repeat transesophageal echocardiography shows trivial residual regurgitation after placement of the septal occluder (arrow). LA, left atrium; LV, left ventricle.