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Figure 4. This 74-year-old man underwent percutaneous repair of a perivalvular leak of his St. Jude mechanical mitral prosthesis. Top left, An apical puncture is performed to snare the guidewire, which has been passed across the leak from the left atrium into the left ventricle. Top right, This snaring allows creation of an exteriorized wire rail, which provides strong support for placing devices across the perivalvular leak. Middle left and right, The guide catheter is advanced through the leak over the rail. Bottom left, A septal occluder is deployed across the leak. Bottom right, Transesophageal echocardiography shows occlusion of the leak with only mild central regurgitation through the septal occluder. This central regurgitation resolves with subsequent endothelialization of the septal occluder. LA, left atrium; LV, left ventricle.