Abstract
Paravalvular regurgitation affects 5–17 % of all surgically implanted prosthetic heart valves. Patients who have paravalvular regurgitation can be asymptomatic or present with symptoms arising from ongoing haemolysis or heart failure. Re-operation is associated with increased morbidity and is not always successful because of underlying tissue friability, inflammation or calcification. Percutaneous paravalvular leak closure is now an established therapy for symptomatic patients (available to view at www.mici.education). Comprehensive echocardiographic imaging with transthoracic echocardiography and three-dimensional transoesophageal echocardiography is key in characterizing defect location, size and shape. With careful anatomical assessment, procedural planning and execution, successful closure rates of 90 % or more are attainable with a low risk of device impingement on the prosthetic valve or embolization.
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Ruiz CE, Jelnin V, Kronzon I. Clinical outcomes in patients undergoing percutaneous closure of periprosthetic paravalvular leaks. J Am Coll Cardiol. 2011;58:2210–7.
Sorajja P, Cabalka AK, Hagler DJ, Rihal CS. Percutaneous repair of paravalvular prosthetic regurgitation: acute and 30-day outcomes in 115 patients. Circ Cardiovasc Interv. 2011;4:314–21.
Sorajja P, Cabalka AK, Hagler DJ, Rihal CS. Long-term follow-up of percutaneous repair of paravalvular prosthetic regurgitation. J Am Coll Cardiol. 2011;58:2218–24.
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Angiographic imaging during para-mitral leak closure via transapical route. Coronary angiography is performed to identify the position of the left anterior descending artery (LAD), to avoid inadvertent damage during transapical puncture (AVI 2222 kb)
Angiographic imaging during para-mitral leak closure via transapical route. A guidewire is introduced through the LV apex and advanced retrogradely across the mitral paravalvular leak into the left atrium. (AVI 592 kb)
Angiographic imaging during para-mitral leak closure via transapical route. A transseptal catheter is positioned in the left atrium, having been introduced via the femoral vein. The retrograde wire is snared and pulled back into the transseptal catheter so creating a circuit (LV apex to femoral vein). (AVI 546 kb)
Angiographic imaging during para-mitral leak closure via transapical route. A sizing balloon has been used to assess dimensions of the defect. (AVI 774 kb)
Angiographic imaging during para-mitral leak closure via transapical route. The occlusion device is advanced through the delivery sheath on a cable, and partially extruded so that the distal disc has been released to conform to its correct shape in the LV. (AVI 424 kb)
Angiographic imaging during para-mitral leak closure via transapical route. The distal disc is pulled back into position against the ventricular aspect of the defect. The proximal disc is released to conform to a position on the atrial side, so occluding the leak. Once the operators are satisfied that the device is stable and not interfering with mitral valve function, the cable is unscrewed to release the occluder. (AVI 2004 kb)
Angiographic imaging during para-mitral leak closure via transapical route. An occlusion coil has been deployed to close the LV apical puncture site. (AVI 465 kb)
Echocardiographic imaging peri and immediately post para-mitral leak closure via transapical route. TOE images showing stable position of mechanical mitral valve replacement (29 mm Bjork-Shiley valve). Stitch dehiscence adjacent to the A2 portion of the native anterior mitral leaflet is demonstrated - resulting in moderate, eccentric mitral regurgitation directed anteriorly. There is an additional small secondary defect around the posterior mitral annulus. (AVI 932 kb)
Echocardiographic imaging peri and immediately post para-mitral leak closure via transapical route. TOE images showing stable position of mechanical mitral valve replacement (29 mm Bjork-Shiley valve). Stitch dehiscence adjacent to the A2 portion of the native anterior mitral leaflet is demonstrated - resulting in moderate, eccentric mitral regurgitation directed anteriorly. There is an additional small secondary defect around the posterior mitral annulus. (AVI 864 kb)
Echocardiographic imaging peri and immediately post para-mitral leak closure via transapical route. TOE images showing stable position of mechanical mitral valve replacement (29 mm Bjork-Shiley valve). Stitch dehiscence adjacent to the A2 portion of the native anterior mitral leaflet is demonstrated - resulting in moderate, eccentric mitral regurgitation directed anteriorly. There is an additional small secondary defect around the posterior mitral annulus. (AVI 745 kb)
Echocardiographic imaging peri and immediately post para-mitral leak closure via transapical route. TOE demonstrating paravalvular closure device in-situ with residual mitral regurgitation at site of anterior leak. (AVI 518 kb)
Echocardiographic imaging peri and immediately post para-mitral leak closure via transapical route. TOE demonstrating paravalvular closure device in-situ with residual mitral regurgitation at site of anterior leak. (AVI 420 kb)
Echocardiographic imaging peri and immediately post para-mitral leak closure via transapical route. Transthoracic post-procedural image showing large haemothorax, which required surgical evacuation. (AVI 644 kb)
Cardiac CT of aortic paravalvular defect to delineate anatomy of the hole to be closed. (AVI 28950 kb)
Retrograde para-aortic leak closure. Angiographic images in two orthogonal plans demonstrating severe aortic regurgitation through large posterior dehiscence extending from 10 to 12 o’clock of standard TOE short axis aortic valve view. A smaller more anterior dehiscence was noted at 7 o’clock. (AVI 2139 kb)
Retrograde para-aortic leak closure. Angiographic images in two orthogonal plans demonstrating severe aortic regurgitation through large posterior dehiscence extending from 10 to 12 o’clock of standard TOE short axis aortic valve view. A smaller more anterior dehiscence was noted at 7 o’clock. (AVI 2164 kb)
Retrograde para-aortic leak closure. Occluder being pushed through the delivery sheath. (WMV 7385 kb)
Retrograde para-aortic leak closure. Two orthogonal angiographic views of device in position, but still attached to its delivery cable. Based on cardiac CT and echocardiographic data, a 5 × 10 mm AVP III device was chosen for deployment. Angiography shows leak through the nitinol mesh, which reduces with time following endothelialisation. (AVI 1559 kb)
Retrograde para-aortic leak closure. Two orthogonal angiographic views of device in position, but still attached to its delivery cable. Based on cardiac CT and echocardiographic data, a 5 × 10 mm AVP III device was chosen for deployment. Angiography shows leak through the nitinol mesh, which reduces with time following endothelialisation. (AVI 1487 kb)
Retrograde para-aortic leak closure. Release of cable from closure device. (WMV 1553 kb)
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Varghese, A., Uren, N., Ludman, P.F. (2017). Percutaneous Paravalvular Leak Closure. In: Varghese, A., Uren, N., Ludman, P. (eds) Cases in Structural Cardiac Intervention. Springer, London. https://doi.org/10.1007/978-1-4471-4981-1_5
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DOI: https://doi.org/10.1007/978-1-4471-4981-1_5
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