Fig. 8.1
The Amplatzer family of devices (1, Amplatzer vascular plug I; 2, vascular plug II; 3, vascular plug III; 4, vascular plug IV; 5, muscular VSD device; 6, Amplatzer Duct Occluder) and Occlutech PLD devices; 7, square device; 8, rectangular device)
8.7 Outcomes
Complications can be divided into those related to TA access and PVL closure. Potential transapical access complications include hemothorax, pericardial effusion, coronary laceration, LV pseudoaneurysm, pneumothorax, cardiac arrhythmia, and death. Hemothorax is the most frequent complication and can be related to coronary or intercostal vessel laceration or bleeding from the LV puncture site. Potential complications related to PVL closure include prosthetic valve interference by device, device embolization, stroke, increased hemolysis, vascular complications, and death.
Good technical success has been reported with both surgical [15, 16] and percutaneous TA PVL closure [6, 17]. In the largest series by Jelnin et al., 28 patients underwent 32 percutaneous transapical punctures. Complications were observed in two patients (7.1%). The complications encountered included pericardial effusion and death. The death occurred in a patient with suprasystemic pulmonary hypertension resulting in electromechanical dissociation following LV apical access [6]. The literature related to TA PVL closure is still limited and more experience is still needed to improve the technical steps and outcome of this procedure.
In a case we recently have done, a patient presented with severe paravalvular mitral leak resulting in severe heart failure and moderate hemolysis. She was taken to the hybrid suite and underwent mitral PVL closure via the percutaneous transapical approach. She had two large leaks in the posteromedial aspect of the mitral valve ring. Prior to closure, her LA pressure was remarkable for an “a” wave of 33 mmHg, “v” wave of 70 mmHg, and mean pressure of 32 mmHg. The first device we used was a 10 mm × 5 mm Occlutech rectangular device. However there was a residual leak, and, unfortunately, we did not have at that time another large rectangular device, and, therefore, a 10 mm Amplatzer muscular VSD device was used. The majority of leak has disappeared, and there was a small residual leak between the devices. We thought this should get better over time. However, that same day, she started to experience significant hemolysis requiring transfusions on a daily basis, and, finally, after 1 week of no improvement in the hemolysis, we decided to take her back to the hybrid suite to close the residual leak. Of note, her heart failure symptoms had improved significantly.
We accessed her LV percutaneously from the apex using a different puncture site in the apex, and we identified the residual leak to be between the devices. After crossing this leak, LA pressure showed significant improvement (“a” wave was 23 mmHg, “v” wave 50 mmHg, and mean 23 mmHg). To eliminate the entire leak without leaving chance for residual leak, we used a 25 mm Amplatzer cribriform device (St. Jude Medical, Inc.). The device after deployment eliminated the residual leak completely and was close to the mitral valve leaflets without causing significant obstruction (mean mitral inflow gradient was about 5–6 mmHg). The procedure was successful to the extent that, at the end of the procedure, the urine color started to clear up in the Foley’s catheter (Fig. 8.2). Figures 8.3 and 8.4 demonstrate the fluoroscopic and echocardiographic images of the first and second procedures to close the paravalvular leaks.
Fig. 8.2
Foley’s catheter during second procedure, after deployment of the last device. Urine before closure shows the hemolysis (red arrow) and fresh urine is clear (white arrow)
Fig. 8.3
The steps of percutaneous TA access in an 84-year-old female patient status post bioprosthetic mitral valve replacement. (a) Infiltration of the skin with Xylocaine. (b) Use of micropuncture needle (0.021 in. gauge) to puncture the LV percutaneously. (c) Passage of the wire (arrow) into the left ventricle cavity. (d) Over the wire, a 7-Fr sheath was inserted and positioned in the LV cavity. (e) A delivery sheath with the Occlutech rectangular device (arrow) at the tip of the sheath. (f) The device (arrow) has been released at its location. (g) Passage of a wire (arrow) in the residual defect beside the already released device. (h) Deployment of one desk (arrow) of a muscular VSD device in the left atrial side of the defect. (i) Closure of the track with a vascular plug II (arrow). One desk is in the endocardium of the left ventricle. (j) Pulling the proximal desk of the plug into the epicardium (arrow). (k) Angiogram via side arm of the short sheath to confirm position of the plug (arrow). (l) Release of the plug (arrow). (m) Puncture of the left ventricle apex for the second procedure beside the first puncture site (arrow). (n) Passage of a sheath beside the first two devices (short-arrow VSD device; long-arrow Occlutech device). (o) Deployment of the left atrial desk (arrow) of a 25 mm cribriform device. (p) Deployment of the ventricular desk of the device while still attached (arrow). (q) Release of the device (arrow). (r) Deployment of muscular VSD device to close the track (arrow). (s) Angiogram via side arm of the sheath to position the VSD device (short arrow), medium size arrow shows last device deployed in the defect and long arrow shows the old vascular plug II used to close the track in the first procedure. (t) The muscular VSD device was positioned in the correct position (one part in the epicardium)
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