Fig. 4.1
Aortic paravalvular leak, single device. A 74-year-old male with paravalvular leak in relation to mechanical aortic valve. The leak is an eccentric leak in the region of the noncoronary cusp and measured 10- × 3-mm on echocardiogram. Right femoral arterial access was obtained and a 5-Fr sheath was placed. A 5-Fr AL1 guide catheter and Terumo hydrophilic 0.035″ wire were used to cross the leak in a retrograde fashion (a). This catheter was exchanged over an Amplatz Extra-Stiff wire for a 7-Fr Cook Shuttle Sheath, which was placed in the left ventricle (b). A 0.014″ Ironman wire was placed as access protection through the paravalvular leak into the left ventricle. A 10-mm PDA occluder device was attempted but was unsuccessful in closing the defect (c) and was removed. The 0.014″ wire stayed in place (d). A 4-Fr 125 cm JR4 catheter was placed coaxial inside the shuttle sheath to traverse the paravalvular leak over the 0.014″ wire and reestablish the shuttle sheath across the leak (not pictured). Then a 12/3-mm AVP III device was placed across the leak (e). After fluoroscopic and echocardiographic confirmation of minimal leak and good valve function, the device was released (f)
Fig. 4.2
Aortic paravalvular leak, multiple leaks. After having a mechanical aortic valve in 2008, the patient presented 4 years later with symptoms of heart failure and severe regurgitation. A 5- × 11-mm PVL was noted near the left coronary cusp and 5- × 8-mm PVL in the area of the noncoronary cusp (a, b). A 5-Fr MP catheter and 0.035″ hydrophilic wire were used to cross the leak near the noncoronary cusp. This was then exchanged over an Amplatz ES 0.035″ wire (c) for a 10-Fr Cook Shuttle Sheath. This was then used to advance an AVP III size 5- × 14-mm device (d), which was then deployed (e). Similar access was obtained through the other femoral artery, and a similar technique was used to cross the leak near the left coronary cusp. An AVP III 5- × 14-mm device was also implanted (f–h). Follow-up echocardiographic views at 42 and 117° show the position of the noncoronary cusp (green arrow) and left coronary cusp (red arrow) devices (i, j). Both aortic and mitral valve leaflets moved well on TEE
Once the device in place, it is important to rule out complications from the device. The prosthetic aortic valve should be evaluated, preferably both by echocardiography and fluoroscopy, to make sure leaflet movement is not compromised (Figs. 4.1 and 4.2). If the device is in the area of the former left and right coronary cusp, coronary patency should be shown, either by selective or root angiography or by TEE. If the device is in the area of the former noncoronary cusp, the anterior mitral valve leaflet should also be evaluated.
Device success consists of a decrease in aortic regurgitation and improvement in symptoms. Regular follow-up with TTE can be performed at 6 months and earlier if symptoms occur. For patients with hemolysis, a hemoglobin/hematocrit level should be checked as well.
4.8 Complications
A variety of complications can occur with paravalvular leak closure [17]. Access-site complications occur between 0.7 and 4 %. Valve interference occurs between 3.5 and 5 %. Other complications include stroke, endocarditis, postprocedural hemolysis, and device erosion. Emergent cardiac surgery may occur 0.7–2 % of the time, and death may occur in 1.4–2 % of cases. One series reported major adverse events with percutaneous PVL closure at 30 days (death, myocardial infarction, stroke, major bleeding, and emergency surgery) at 8.7 % [17].
Devices that embolize from the aortic position may travel anywhere. Larger devices are less likely to go cranially and are often found at the iliac bifurcation. The same holds true for devices that embolize from the mitral position; however, the risk holds that they may get caught in the left ventricular outflow tract. Surgery is often indicated in these cases.
For postprocedural hemolysis, this usually resolves after complete endothelialization. This may take up to 6 months.
4.9 Long-Term Results
Technical success, as defined by Kliger et al. [17], is correct deployment of an occlusive defect without significant residual regurgitation or new prosthetic valve malfunction. Clinical success may be an improvement in NYHA functional class by at least one grade and/or improvement in mechanical hemolysis. There are two large case series with 57 [12] and 141 [22] PVL closures. Technical success ranges from 77 to 86 % and clinical success from 67 to 77 %. Ruiz et al. [12] reported long-term follow-up at 6, 12, and 18 months as 91.9 %, 89.2 %, and 86.5 %, respectively. Sorajja et al. [23] found 1–2-year survival after PVL closure of 70–75 % with an estimated 3-year survival of 64.5 %.
Conclusion
Treatment of paravalvular regurgitation requires careful preprocedural imaging, planning, and patient selection. Through principles of access, technique, and device choice, it is possible to achieve both technical and clinical success. It has become the primary therapy of choice in appropriately selected cases.
References
1.
Vongpatanasin W, Hillis LD, Lange RA. Prosthetic heart valves. N Engl J Med. 1996;335:407–16.CrossRefPubMed
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