Fig. 7.1
Aortic paravalvular leak located in the left coronary sinus. Fluoroscopic projection perpendicular to the plane of the prosthetic valve. Telescopic system with 6F AL1 guide catheter (above the PVL) and 5F long JR diagnostic catheter in the left ventricle
Several techniques can facilitate the crossing:
Increased support by means of a second 0.014″ coronary wire or 0.018″ extra support wire (e.g., V-18 Control Wire, Boston Scientific).
If a 5F diagnostic catheter is used to cross the PVL, it might be used to introduce 0.035–0.038″ wire to increase support for crossing with a 6F guide (if it is used for plug delivery) or an alternative delivery sheath.
Use of a long 300 cm coronary guide, withdrawal of the 5F diagnostic catheter, and dilatation of the channel with 2.5 mm balloon. Such an approach may provide gradual tapering of the tip of the guide catheter and modify the calcifications within the PVL, but does not usually increase the diameter of the leak. Also, inflation of the balloon can provide valuable information on the anatomy of the leak, and use of the TOE with a color Doppler can improve the sizing of the leak. Use of the partially inflated balloon facilitates the crossing with a delivery catheter or sheath (Fig. 7.2). This technique is not useful, however, when the PVL consists of multiple channels separated by surgical sutures.
Fig. 7.2
Aortic paravalvular leak located in the non-coronary sinus. Inflated 2.5 × 20 mm coronary balloon in PVL channel and JR guide catheter (arrowheads)
In the majority of cases, these techniques allow for the crossing of the PVL with a delivery sheath or catheter sized according to the type and size of the device and in the case of a multiplug approach to their number.
Several approaches can accomplish the delivery of the plug(s):
- 1.
Use of a single PLD device
The design of the paravalvular leak device (PLD, Occlutech, Switzerland) was discussed in previous chapter and previously published [5, 6]. It is particularly suitable for PVL devices of a length shorter than 4–5 mm. In terms of the implantation technique, the following issues are important:
Rectangular occluders have two radiopaque markers in the middle of the longer axis, and these should be maximally separated to allow alignment with the long axis of the leak.
The occluder is connected to the delivery cable by the bulb and socket-type connection, so the torque of the delivery cable does not translate into the rotation of the plug. Proper orientation of the device can be achieved by the withdrawal of the proximal disc into the delivery sheath and its torque. In cases in which this is not possible, the plug can be advanced into the left ventricle and withdrawn slowly. After several attempts, the left ventricle wall movement may produce the proper alignment of the device.
The distal part of the delivery cable consists of the stiff metallic tubular element. In cases of an oblique PLV track and in patients with a small diameter of the aorta at the level of sinuses of Valsalva and sinotubular junction, this feature of the device may increase the procedural complexity.
The W-type PLD should not be oversized. In fact, a small undersizing might be of advantage. The occluder should be sized based on the nominal size. Notably, the size given for the W-type occluders refers to the waist, not the proximal and distal discs [6].
Exemplary Case
In a patient with PVL located in the non-coronary sinus, the strategy was to implant a single rectangular 6 × 3 mm W-type PLD occluder. The PVL was crossed with a 110 cm 7F delivery sheath, and the occluder was introduced into the left ventricle. It was impossible to rotate the occluder due to the tension and bend of the delivery sheath. The sheath was withdrawn into the PVL channel, and the occluder loosely protruded into the ventricle allowing for spontaneous rotation with the wall movement. This technique led to self-orientation of the plug which subsequently was withdrawn into the sheath in a manner in which the proximal disc was retracted into the sheath just distal to the end of the PVL ( Fig. 7.3a ). Subsequently, the proximal disc was deployed on the aortic side of the PVL by the withdrawal of the sheath. After the stability test (pull and push technique) and fluoroscopic evaluation of the movement of the prosthetic valve discs and assessment of the residual leak by TOE, the PLD was released. The final result is shown in Fig. 7.3b .
- 2.
Sequential implantation of single/multiple AVP III occluders
AVP III plugs can be implanted individually or using a multiplug technique [7–9]. In the first instance, a larger size of the plug is necessary. It is associated with the increased length of the plugs which, in the case of shorter channels, can lead to excessive overhanging of the distal discs and possibly collision with the disc of the valvular prosthesis. Another solution is to implant two or more smaller and shorter plugs into the single PVL channel which leads to improved filling of the leak channel.
Fig. 7.3
Panel (a) The 6 × 3W PLD occluder in the left ventricle with two separated radiopaque markers indicating the proper orientation in relation the long axis of the leak. Panel (b) Implanted PLD occluder. Please note that the axis of the PVL is almost perpendicular to the annulus
Exemplary Procedure
Figure 7.4 shows the implantation of two 6 × 3 mm AVP III occluders through a single 7F delivery sheath. One occluder was fully deployed in the left ventricle, while the second was partially (proximal disc) withdrawn into the sheath. The sheath was withdrawn into the implantation position on the aortic side of the leak (Fig. 7.4a ). The first occluder was fully deployed. As the next step, the sheath was forwarded toward the proximal disc acting as a support preventing it from being withdrawn from the PVL channel. The second occluder was pulled through the leak providing full sealing. The final effect is shown in Fig. 7.4b .
Fig. 7.4
Panel (a) Step one: first AVP III plug (arrow) just before the deployment of the proximal (aortic) disc, second plug (arrowhead) in the left ventricle. Panel (b) Step two: both occluders deployed, before release from delivery cable
Such a technique is an alternative to the simultaneous deployment of two occluders through a single delivery sheath. It provides better tracking control and lessens the risk of pulling occluders out of the channel. It is technically more demanding, however. Also, it is important to understand that the plug is connected to the delivery cable by a screw, so there is a potential risk that the plugs might spontaneously unscrew if the plugs move loosely with the left ventricle before implantation.
In case there is a need to implant more than two AVP III plugs, several approaches are possible:
Figure 7.5 shows the simultaneous implantation of three 6 × 3 mm AVP III plugs through the 8F delivery sheath in a patient with large PVL located in the non-coronary cusp. The size of the leak and lack of calcifications allowed for the easy passage of the delivery sheath. Distal discs of all three occluders were simultaneously exposed from the sheath in the ventricle and were pulled into contact with the prosthetic valve. Through withdrawal of the sheath, the occluders were deployed in the proper position. In such cases, the sequential deployment of the plugs is also feasible as shown in Fig. 7.6 . The first two occluders are deployed simultaneously (Fig. 7.6a ), followed by delivery of the third plug (Fig. 7.6b ).
Fig. 7.5
Multiplug technique. Simultaneous deployment of three AVP III plugs into the PVL related to aortic bioprosthesis
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