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Interventional Management in Patients with Paravalvular Leaks

  • Ted Feldman
  • Michael H. Salinger
  • Mayra Guerrero
  • Paul Pearson
Chapter

Abstract

Paravalvular leak (PVL) closure is an increasingly frequently used procedure in structural intervention programs. Historical reviews suggest an incidence of PVL in the range of 1–2% after surgical valve replacement, and 2–20% after transcatheter aortic valve replacement. Heart failure and hemolysis may result from these leaks, and are the main indications for intervention. Reoperation is high risk since in all of these patients re-thoracotomies and redo operations would be needed; in addition, many of these patients have multiple co-morbidities. Percutaneous closure has developed as a therapy for this clinical condition. The use of three-dimensional transesophageal echocardiography and computed tomography has greatly facilitated the use of catheter methods to assess and treat PVL. Most PVL closure procedures are performed with both fluoroscopic and transesophageal echocardiographic imaging. It is usually difficult or even impossible to determine the site of a leak by angiography alone. Several different plug devices are used for these procedures. Most of these plugs are designed for general vascular use, with only a few designed especially for PVL closure. Catheter delivery is accomplished using trans-septal, retrograde aortic, and transapical approaches. Percutaneous closure of PVL improves both leak severity and symptoms. The technical challenges associated with PVL closure are numerous. Basic skills for crossing leaks with wires are substantial and often require a great deal of patience, flexibility, and a wide array of equipment. Percutaneous closure should be considered as an important alternative to repeat surgery associated with a high early mortality. Earlier leak closure prior to the onset of symptoms and signs of congestive heart failure or the development of hemolysis may ultimately achieve better outcomes of PVL closure.

References

  1. 1.
    Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol. 2000;36:1152–8.CrossRefPubMedGoogle Scholar
  2. 2.
    O’Rourke DJ, Palac RT, Malenka DJ, Marrin CA, Arbuckle BE, Plehn JF. Outcome of mild periprosthetic regurgitation detected by intraoperative transe- sophageal echocardiography. J Am Coll Cardiol. 2001;38:163–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Rihal CS, Sorajja P, Booker JD, Hagler DJ, Cabalka AK. Principles of percutaneous paravalvular leak closure. JACC Cardiovasc Interv. 2012;5(2):121–30.  https://doi.org/10.1016/j.jcin.2011.11.007.CrossRefPubMedGoogle Scholar
  4. 4.
    Duncan BF, McCarthy PM, Kruse J, Andrei AC, Li Z, Russell HM, Abicht TO, Rigolin VH, Thomas JD, Davidson CJ, Bonow RO, Malaisrie SC. Paravalvular regurgitation after conventional aortic and mitral valve replacement: a benchmark for alternative approaches. J Thorac Cardiovasc Surg. 2015;150(4):860–8.e1.  https://doi.org/10.1016/j.jtcvs.2015.06.047.CrossRefPubMedGoogle Scholar
  5. 5.
    Rothlin ME, Egloff L, Kugelmeier J, Turina M, Senning A. Reoperations after valvular heart surgery: indications and late results. Thorac Cardiovasc Surg. 1980;28(2):71–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Bouhout I, Mazine A, Ghoneim A, Millan X, El-Hamamsy I, Pellerin M, et al. Long-term results after surgical treatment of paravalvular leak in the aortic and mitral position. J Thorac Cardiovasc Surg. 2016;151:1260–6.e1.CrossRefPubMedGoogle Scholar
  7. 7.
    Miceli A, Santarpino G, Pfeiffer S, Murzi M, Gilmanov D, Concistre G, et al. Minimally invasive aortic valve replacement with Perceval S sutureless valve: early outcomes and one-year survival from two European centers. J Thorac Cardiovasc Surg. 2014;148:2838–43.CrossRefPubMedGoogle Scholar
  8. 8.
    Kocher AA, Laufer G, Haverich A, ShresthaM WT, Misfeld M, et al. One- year outcomes of the surgical treatment of aortic stenosis with a next generation surgical aortic valve (TRITON) trial: a prospective multicenter study of rapid-deployment aortic valve replacement with the EDWARDS INTUITY valve System. J Thorac Cardiovasc Surg. 2013;145:110–6.CrossRefPubMedGoogle Scholar
  9. 9.
    Thourani VH, Kodali S, Makkar RR, Herrmann HC, Williams M, Babaliaros V, Smalling R, Lim S, Malaisrie SC, Kapadia S, Szeto WY, Greason KL, Kereiakes D, Ailawadi G, Whisenant BK, Devireddy C, Leipsic J, Hahn RT, Pibarot P, Weissman NJ, Jaber WA, Cohen DJ, Suri R, Tuzcu EM, Svensson LG, Webb JG, Moses JW, Mack MJ, Miller DC, Smith CR, Alu MC, Parvataneni R, D'Agostino RB Jr, Leon MB. Transcatheter aortic valve replacement versus surgical valve replacement in intermediate-risk patients: a propensity score analysis. Lancet. 2016;387(10034):2218–25.  https://doi.org/10.1016/S0140-6736(16)30073-3. Epub 2016 Apr 3CrossRefPubMedGoogle Scholar
  10. 10.
    Meredith IT, Walters D, Dumonteil N, Worthley SG, Tchétché D, Manoharan G, Blackman DJ, Rioufol G, Hildick-Smith D, Whitbourn RJ, Lefèvre T, Lange R, Müller R, Redwood S, Feldman TE, Allocco DJ, Dawkins KD. One-year outcomes with the fully repositionable and retrievable Lotus Transcatheter aortic replacement valve in 120 high-risk surgical patients with severe aortic stenosis: results from the REPRISE II study. J Am Coll Cardiol Intervent. 2016;9:376–84.CrossRefGoogle Scholar
  11. 11.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP III, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM III, Thomas JD. 2014 AHA/ ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;63:e57–185.CrossRefPubMedGoogle Scholar
  12. 12.
    Taramasso M, Maisano F, Latib A, Denti P, Guidotti A, Sticchi A, et al. Conventional surgery and transcatheter closure via surgical transapical approach for paravalvular leak repair in high-risk patients: results from a single-centre experience. Eur Heart J Cardiovasc Imaging. 2014;15:1161–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Williams MR, Koeckert MS, Grossi EA. Rethinking the gold standard for correction of paravalvular leak. J Thorac Cardiovasc Surg. 2016;151:1267–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Angulo-Llanos R, Sarnago-Cebada F, Rivera AR, Corrales JE, Cuerpo G, Solis J, Gutierrez-Ibañes E, Sanz-Ruiz R, MEV Á, Fernandez-Avilés F. Two-year follow up after surgical versus percutaneous paravalvular leak closure: a non randomized analysis. Cathet Cardiovac Intervent. 2016;88(4):626–34.CrossRefGoogle Scholar
  15. 15.
    Feldman T, Nietlispach F. Surgical vs percutaneous approaches to paravalvular leak: is closure too little too late, or just not soon enough. Catheter Cardiovasc Intervent. 2016;88(4):634–5. in press.CrossRefGoogle Scholar
  16. 16.
    Murakami T, Fujii H, Sakaguchi M, Takahashi Y, Suehiro Y, Nishimura S, Sakon Y, Yasumizu D, Sohgawa E, Shibata T. Intravascular ultrasound for transcatheter paravalvular leak closure. Gen Thorac Cardiovasc Surg. 2016;65(8):466–9. [Epub ahead of print]CrossRefPubMedGoogle Scholar
  17. 17.
    Balzer J, Zeus T, Hellhammer K, Veulemans V, Eschenhagen S, Kehmeier E, Meyer C, Rassaf T, Kelm M. Initial clinical experience using the EchoNavigator(®)-system during structural heart disease interventions.world. J Cardiol. 2015;7(9):562–70.  https://doi.org/10.4330/wjc.v7.i9.562.CrossRefGoogle Scholar
  18. 18.
    Krishnaswamy A, Tuzcu EM, Kapadia SR. Integration of MDCT and fluoroscopy using C-arm computed tomography to guide structural cardiac interventions in the cardiac catheterization laboratory. Catheter Cardiovasc Interv. 2015;85(1):139–47.  https://doi.org/10.1002/ccd.25392. Epub 2014 Jan.CrossRefPubMedGoogle Scholar
  19. 19.
    Arribas-Jimenez A, Rama-Merchan JC, Barreiro-Pérez M, Merchan-Gómez S, Iscar-Galán A, Martín-García A, Nieto-Ballestero F, Sánchez-Corral E, Rodriguez-Collado J, Cruz-González I, Sanchez PL. Utility of real-time 3-dimensional transesophageal echocardiography in the assessment of mitral paravalvular leak. Circ J. 2016;80(3):738–44.  https://doi.org/10.1253/circj.CJ-15-0802.CrossRefPubMedGoogle Scholar
  20. 20.
    Hourihan M, Perry SB, Mandell VS, Keane JF, Rome JJ, Bittl JA, Lock JE. Transcatheter umbrella closure of valvular and paravalvular leaks. J Am Coll Cardiol. 1992;20(6):1371–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Guerrero M, Pursnani A, Salinger MH, Levisay JP, Pearson P, Feldman T. Techniques for percutaneous left ventricular apical access. Cardiac Interven Today. 2015:48–52. http://citoday.com/2015/08/techniques-for-percutaneous-left-ventricular-apical-access/.
  22. 22.
    Luu J, Ali O, Feldman TE, Price MJ. Percutaneous closure of paravalvular leak after Transcatheter aortic valve replacement. J Am Coll Cardol- Cardiovasc. 2013;6(2):e6–8.  https://doi.org/10.1016/j.jcin.2012.08.026.CrossRefGoogle Scholar
  23. 23.
    Feldman T. Paravalvular leak closure after TAVR: technical challenges and clinical utility. Cathet Cardiovasc Intervent. 2015;85:665–6.CrossRefGoogle Scholar
  24. 24.
    Feldman T, Salinger MH, Levisay JP, Smart S. Low profile vascular plugs for paravalvular leaks after TAVR. Catheter Cardiovasc Interv. 2014;83(2):280–8.  https://doi.org/10.1002/ccd.25202. Epub 2013 Oct 19.CrossRefPubMedGoogle Scholar
  25. 25.
    Taramasso M, Maisano F, Denti P, Guidotti A, Sticchi A, Pozzoli A, Buzzatti N, De Bonis M, La Canna G, Alfieri O. Surgical treatment of paravalvular leak: long-term results in a single-center experience (up to 14 years). J Thorac Cardiovasc Surg. 2015;149(5):1270–5.  https://doi.org/10.1016/j.jtcvs.2014.12.041.CrossRefPubMedGoogle Scholar
  26. 26.
    Choi JW, Hwang HY, Kim KH, Kim KB, Ahn H. Long-term results of surgical correction for mitral paravalvular leak: repair versus re-replacement. J Heart Valve Dis. 2013;22(5):682–7.PubMedGoogle Scholar
  27. 27.
    Calvert PA, Northridge D, Malik IS, Shapiro L, Ludman P, Qureshi SA, Mullen M, Henderson R, Turner M, Been M, Walsh KP, Casserly I, Morrison L, Walker NL, Thomson J, Spence MS, Mahadevan VS, Hoye A, MacCarthy P, Daniels MJ, Clift P, Davies WR, Adamson PD, Morgan G, Aggarwal SK, Ismail Y, Ormerod JO, Khan HR, Chandran SS, DeGiovanni J, Rana BS, Ormerod O, Hildick-Smith D. Percutaneous device closure of paravalvular leak: combined experience from the United Kingdom and Ireland. Circulation. 2016;134(13):934–44. pii: CIRCULATIONAHA.116.022684. [Epub ahead of print] PMID: 27587432.CrossRefPubMedGoogle Scholar
  28. 28.
    Kliger C, Eiros R, Isasti G, Einhorn B, Jelnin V, Cohen H, Kronzon I, Perk G, Fontana GP, Ruiz CE. Review of surgical prosthetic paravalvular leaks: diagnosis and catheter-based closure. Eur Heart J. 2013;34(9):638–49.  https://doi.org/10.1093/eurheartj/ehs347. Epub 2012 Nov 1. Review. PMID: 23117162.CrossRefPubMedGoogle Scholar
  29. 29.
    Nietlispach F, Maisano F, Sorajja P, Leon MB, Rihal C, Feldman T. Percutaneous paravalvular leak closure: chasing the chameleon. Eur Heart J. 2016;37(47):3495–502. pii: ehw165. [Epub ahead of print] Review. PMID: 27161614.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Ted Feldman
    • 1
    • 2
  • Michael H. Salinger
    • 1
  • Mayra Guerrero
    • 1
  • Paul Pearson
    • 1
  1. 1.NorthShore University HealthSystemEvanstonUSA
  2. 2.Evanston Hospital, Cardiology Division-Walgreen BuildingEvanstonUSA

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