Percutaneous closure of prosthetic paravalvular leaks: Case series and review

Percutaneous versus surgical closure of paravalvular leaks in prosthetic valves: A cross-sectional comparison of clinical outcomes

Background and Aims

Paravalvular leak (PVL) is a serious complication of prosthetic valve replacement. Both surgical and percutaneous closure techniques are used for PVL closure, but optimal strategies and comparative outcomes are uncertain. This study aimed to compare the efficacy and safety of percutaneous versus surgical PVL closure by analyzing changes in leak severity, functional status, echocardiographic parameters, and clinical outcomes.

Methods

A total of 72 patients were included in this retrospective cross-sectional single-center study comparing percutaneous (n = 25) and surgical (n = 47) PVL closure from 2015 to 2022. Demographics, medical history, echocardiograms, laboratory data, complications, and mortality data were extracted from the records. Changes in leak severity, NYHA class, echocardiographic parameters, and clinical outcomes were compared between the percutaneous and surgical groups.

Results

Both percutaneous and surgical PVL closure significantly reduced leak severity and improved NYHA class (both p < 0.01), with no difference between the quantity of changes in each group. The 30-day mortality was 4% after percutaneous and 6.4% after surgical closure (p = 0.65). At 90 days, mortality was 24% percutaneous versus 17% surgical (p = 0.48). The length of stay in the hospital and post-procedural decrease in hemoglobin were considerably lower in the percutaneous group. The rate of complication rates was similar between the groups. Echocardiographic changes were also comparable.

Conclusion

Percutaneous and surgical PVL closure had similar efficacy in reducing leaks and improving symptoms, with no significant difference in early outcomes. Both options should be considered viable for PVL repair after heart team evaluation.

Complications of transcatheter paravalvular leak device closure of mitral valve: An updated review of the literature and a rare case presentation

Paravalvular leak (PVL) is an uncommon complication of prosthetic valve implantation, which can lead to infective endocarditis, heart failure, and hemolytic anemia. Surgical reintervention of PVLs is associated with high mortality rates. Transcatheter PVL closure (TPVLc) has emerged as an alternative to surgical reoperation. This method provides a high success rate with a low rate of complications. This article reviews the pathogenesis, clinical manifestation, diagnosis, and management of PVL and complications following TPVLc. Besides, we presented a case of a patient with severe PVL following mitral valve replacement, who experienced complete heart block (CHB) during TPVLc. The first TPVLc procedure failed in our patient due to possible AV-node insult during catheterization. After 1 week of persistent CHB, a permanent pacemaker was implanted. The defect was successfully passed using the previous attempt. Considering the advantages of TPVLc, procedure failure should be regarded as a concern. TPVLc should be performed by experienced medical teams in carefully selected patients.

Transcatheter closure of an acquired post-operative aorta to right ventricle shunt in a child with complex univentricular heart

KONAR-Multifunctional^TM VSD Occluder (Lifetech, Shenzhen, China) is one of the most recent additions to the armamentarium of device closure interventions offering special features to tackle complex cardiac anatomies. Herein, we report the first use of the KONAR-MFO in an 8.5-year-old female patient (27 kg/129 cm) with stage III palliated univentricular heart to close an acquired post-operative tunnel-like communication (5 mm long × 2.6 mm large) between the right anterior non-coronary aortic sinus and the rudimentary right ventricular cavity. The shunt was diagnosed two and a half years after bulboventricular foramen surgical enlargement. The 5× 3 mm KONAR-MFO was retrogradely implanted under ultrasound and biplane fluoroscopic guidance. Immediate and 12-month follow-up confirmed successful outcomes with complete shunt closure and preserved aortic valve competence.

Review of Prosthetic Paravalvular Leaks: Diagnosis and Management

PURPOSE OF REVIEW

Paravalvular leak (PVL) is a relatively uncommon complication associated with prosthetic valve implantation. PVL can occasionally lead to serious adverse consequences such as congestive heart failure, infective endocarditis, and hemolytic anemia. Surgical re-operation carries a high mortality risk.

RECENT FINDINGS

Transcatheter closure therapy provides a viable alternative for the treatment of this disorder with reasonable procedural and clinical success. The recent advent of hybrid imaging modalities has increased procedural success. This article summarizes the pathophysiology, clinical characteristics, and treatment modalities surroundings prosthetic paravalvular leak.

The fifth redo operation for mitral paravalvular leakage and free-floating closure device extraction: A case report

Paravalvular leakage (PVL) is a serious complication of prosthetic valve surgery. Surgical and transcatheter methods can be used for treatment. It is rare for closure devices to detach and free float in cardiac chambers. Transcatheter methods can be reused, but surgical treatment is more appropriate if this reuse is due to an increase in PVL. Here, we present a successfully operated case with a closure device freely passing through the PVL from the ventricle to the atrium, after four surgical valve replacements and two transcatheter device closures, owing to infective endocarditis.

Red blood cell abnormalities occur in dogs with congenital ventricular outflow tract obstruction

OBJECTIVE

To document RBC abnormalities in dogs with congenital ventricular outflow tract obstruction.

ANIMALS

62 dogs with pulmonic stenosis (PS) or aortic stenosis (AS) and 20 control dogs were recruited.

PROCEDURES

The proportions of RBCs that were schistocytes, acanthocytes, and keratocytes were assessed. Complete blood cell counts were performed. Tested variables included hemoglobin concentration, hematocrit, and erythrocyte count.

RESULTS

Median (interquartile range [IQR]) peak systolic Doppler-derived trans-stenotic pressure gradient (∆P) values were 161 mm Hg (108 to 215 mm Hg) and 134 mm Hg (125 to 165 mm Hg) for dogs with PS and AS, respectively. Hematologic abnormalities were detected in most dogs with AS or PS (54/62 [87%]) versus 8/20 [40%] in control dogs, with schistocytes found in 40 of 62 (65%; median, 0.1% RBCs; IQR, 0% to 0.3%), acanthocytes in 29 of 62 (47%; median, 0.3% RBCs; IQR, 0% to 0.9%), keratocytes in 39 of 62 (63%; median, 0% RBCs; IQR, 0% to 0.2%), and hemolytic anemia in 4 dogs with PS. No significant association was identified between these abnormalities and ∆P. However, 3 of 4 dogs with anemia had a ∆P > 200 mm Hg (range, 242 to 340 mm Hg). The dog with the highest ∆P value also had the most severe anemia and schistocytosis, and both resolved after balloon valvuloplasty.

CLINICAL RELEVANCE

Poikilocytosis is common in dogs with congenital ventricular outflow tract obstruction, with anemia only observed in few dogs with high ∆P values.

Mitral valve paravalvular leaks: Comprehensive review of literature

BACKGROUND

Mitral paravalvular leaks (mPVL) are a recognized complication for patients with mitral valve prostheses. Although clinically insignificant for many patients, it may pose life-threatening haemolysis and regurgitation-induced heart failure, and so clinicians should have a high index of suspicion in the presence of new symptoms.

AIMS

This review discusses the pathogenesis, clinical features, diagnosis, imaging and treatment of mPVLs.

METHODS

A comprehensive literature search was performed using PubMed, EMBASE, Cochrane database, Google Scholar and Ovid. Search terms used included "mitral valve paravalvular leak," "transthoracic echocardiography," "2D transoesophageal echocardiography," "3D transoesophageal echocardiography," "cardiac computed tomography," (CT) "cardiac magnetic resonance imaging," "intracardiac echocardiography," "cinefluoroscopy," "fluoroscopy," and "percutaneous closure."

RESULTS

All patients with mPVLs should undergo regular full evaluation, including patient history, physical examination, laboratory work-up, imaging, and referral, if necessary. Echocardiography is fundamental to the diagnosis, and is augmented with cardiac magnetic resonance imaging, cardiac computerized tomography and fluoroscopy for further characterization and procedural planning amongst the structural heart team.

CONCLUSION

The prevalence of mPVL is expected to increase proportionally to the growing number of surgical and transcatheter valve replacements conducted in the ageing population. Multimodal imaging is instrumental in guiding diagnostic and therapeutic strategies when managing mPVLs. Advances in imaging and capabilities of transcather devices will prompt growing uptake of percutaneous treatment over conventional, higher-risk surgery for mPVL management.

Intraoperative repair of mitral paravalvular leak with Amplatzer plug

BACKGROUND AND AIM OF THE STUDY

Significant paravalvular leaks may complicate mitral valve replacement (MVR), especially in the setting of mitral annular calcification. Correction has been accomplished postoperatively by endovascular delivery of Amplatzer plugs (Abbott Medical) with good results. Intraoperative delivery of Amplatzer plugs at the index operation may reduce postoperative paravalvular leaks.

METHODS

A retrospective review of eight patients who underwent placement of Amplatzer plugs for treatment of paravalvular leak during MVR at a single institution is reported.

RESULTS

Seven patients had ≤1+ residual mitral valve insufficiency and one patient had 1-2+ residual mitral valve insufficiency intraoperatively by transesophageal echocardiogram. At 222 days average follow-up, echocardiogram revealed ≤ 1+ residual mitral valve insufficiency in all surviving patients.

CONCLUSION

Intraoperative delivery of Amplatzer plugs for treatment of paravalvular leaks during MVR appears to be safe and effective at reducing postoperative mitral valve insufficiency.

Aorta-to-right ventricle neoshunt closure using an Amplatzer Duct Occluder II device

We report the case of a 22-year-old female patient with complex congenital heart disease and multiple cardiac surgeries who came to our attention for right heart failure and hemolysis 3 years after aortic valve replacement surgery. She was diagnosed with aorta-to-right ventricle fistula and was efficiently treated with retrograde implantation of an Amplatzer Duct Occluder II device using three-dimensional multimodality fusion imaging.

In Vitro and Ex Vivo Hemodynamic Testing of an Innovative Occluder for Paravalvular Leak After Transcather Aortic Valve Implantation

This study aims at achieving a proof-of-concept for a novel device designed to occlude the orifices that may form between transcatheter valves and host tissues after TAVI. The device effect on the performance of a SAPIEN XT with a paravalvular gap was assessed into an in vitro and ex vivo pulse duplicator. The in vitro tests were performed complying with the standard international regulations, measuring the trasvalvular pressure and regurgitant volumes with and without the paravalvular gap, and with the occluder correctly positioned into the gap. In the second series of tests, the leakage reduction due to the presence of the occluder was assessed for the same setup, into a beating swine heart. The occluder implantation decreased the regurgitant fraction of about 50% for the in vitro assessment and 75% for the ex vivo test, under rest operating conditions. These results suggest that suitably designed occluders can lead to important benefit in the PVL treatment.

Right main bronchus para-occluder fistula closure with a septal defect occluder

We present a case of successful closure of a para-occluder fistula. The bronchopleural fistula occurred after a right-sided pneumonectomy performed for multidrug-resistant tuberculosis. Initial closure of the bronchopleural fistula with the use of an atrial septal defect occluder 3 years later led to relapse of the fistula after 2 years. To manage the relapsing bronchopleural fistula, we partially destroyed the former nonfunctioning occluder, measured the size of the bronchial defect with a sizing balloon, and installed an atrial septal defect occluder of a larger size.

Feasibility of transcatheter prosthetic paravalvular leakage closure: a single-center, exploratory safety evaluation study of transcatheter closure of prosthetic paravalvular regurgitation in Japan (STOP PARA study)

OBJECTIVE

The standard treatment of prosthetic paravalvular leakage (PVL) accompanied by heart failure or hemolytic anemia is repeat open surgery. Although favorable outcomes for transcatheter prosthetic PVL closure in patients with a high surgical risk for repeat open surgery have been reported, procedural feasibility has not been examined in Japan.

METHODS

From March 2015 to November 2015, transcatheter PVL closure in mitral position was performed in four patients (age range 41-78, three females) with high surgical risk due to history of repeated surgeries, chest radiation and reconstruction of the mitral annulus after debridement of abscess owing to infective endocarditis. All procedures were performed via a transapical approach under general anesthesia.

RESULTS

Of four patients, the indications for PVL closure of two patients were heart failure, and those of the others were hemolytic anemia. There were no major complications, mortalities, or prolonged intensive care unit or hospital stays. Technical success was achieved in two patients. Moderate paravalvular regurgitation persisted in one patient, although regurgitation reduction of one grade was obtained. In one patient, occluder devices were not deployed because the wire could not cross the defect. Improvement in New York Heart Association functional class compared with that at baseline was observed in two patients.

CONCLUSIONS

The safety and acute technical success rates of transcatheter mitral PVL closure via a transapical approach were confirmed in Japanese patients. In Japan, transcatheter PVL closure may be an alternative option for patients with PVL who have a high surgical risk.

Retrograde transmitral paravalvular leak closure through an antegrade transseptal approach: A novel technique

Mitral paravalvular leak (PVL) remains a well-known complication after mitral valve replacement. Since the first report over 25 years ago, several catheter-based PVL closure techniques have been described. Most of these comprise of either an antegrade transseptal approach, or a retrograde transaortic or transapical approach. We herein report a novel percutaneous mitral PVL closure technique that was safely and successfully performed after failed attempt using a conventional antegrade approach.

Meta-analysis Comparing Transcatheter and Surgical Treatments of Paravalvular Leaks

Percutaneous paravalvular leak (PVL) closure has emerged as a feasible alternative to redo valve surgery. However, comparative data on percutaneous and surgical treatment of PVL are scarce. We performed a systematic review and a meta-analysis of studies on percutaneous and surgical treatments of PVL. Of the 2,267 studies screened, 22 eligible studies were analyzed. Primary end points were technical success, 30-day mortality, stroke, and length of stay. Secondary end points were 1-year mortality, readmission for heart failure, reoperation, and symptomatic improvement at follow-up. A total of 2,373 patients were included, of whom 1,511 (63.7%) underwent percutaneous closure. Technical success was higher with surgery (96.7% vs 72.1%, odds ratio [OR] 9.7, p <0.001) but at the cost of higher 30-day mortality (8.6% vs 6.8%, OR 1.90, p <0.001), a trend toward higher stroke (3.3% vs 1.4%, OR 1.94, p = 0.069), and longer hospitalizations. However, surgery was associated with similar 1-year mortality (17.3% vs 17.2%, OR 1.07, p = 0.67), reoperation (9.1% vs 9.9%, OR 0.72, p = 0.1), readmission for heart failure (13.3% vs 26.4%, OR 0.51, p = 0.29), and improvement in New York Heart Association classification (67.4% vs 56%, OR 1.37, p = 0.74), compared with percutaneous closure. A sensitivity analysis including comparative studies only yielded similar results. Surgical treatment of PVL achieves higher technical success rates but is associated with higher early morbidity and mortality compared with percutaneous closure. Nevertheless, mortality rates and clinical efficacy parameters were similar at midterm with both procedures. Further studies are warranted to identify the ideal management approach to patients with symptomatic PVL.

Retrospective analysis of single-center early and midterm results of transapical catheter-based mitral paravalvular leak closure with a purpose-specific device

Introduction

Due to the recent lack of definitions to establish the severity of paravalvular leak (PVL) and endpoints for its treatment, the effectiveness and safety of a new device for PVL closure have not been comprehensively analyzed.

Aim

To analyze a single center’s experience of mitral PVL closure in a surgical transapical catheter-based fashion with a purpose-specific device.

Material and methods

This is a retrospective cohort study of patients following transapical catheter-based mitral PVL closure with a purpose-specific device. Data were analyzed at baseline, perioperatively, at discharge, at six months and annually after the procedure.

Results

Nineteen patients underwent surgical transapical catheter-based mitral PVL closure with the Occlutech PLD Occluder. Mean follow-up time was 20 ±7 (range: 9–33) months. The patients’ mean age was 64 ±7 years, and 11 (58%) were male. Technical, device and individual patient success at follow-up was achieved in 18 (95%), 16 (84%) and 16 (84%) patients respectively. Median intensive therapy unit stay was one day (1–4) and mean hospital stay was 11 ±4 days. A reduction of paravalvular regurgitation to a mild or lesser degree was achieved in 18 (95%) patients. There were no strokes or myocardial infarctions at follow-up. There were no deaths at 30 days after the procedure. One (5%) patient expired due to progression of heart failure 12 months after surgery. None of the patients required immediate conversion to full sternotomy.

Conclusions

Surgical transapical catheter-based mitral PVL closure with the Occlutech PLD Occluder is a safe and clinically effective treatment.

Interventional treatment of paravalvular regurgitation by plug implantation following prosthetic valve replacement: a single-center experience

BACKGROUND

Interventional closure of paravalvular leaks (PVL) by plug implantation has emerged as an alternative to surgical correction, which is associated with high mortality rates for re-operation. To date, data on procedural efficacy and clinical outcome after transcatheter closure is sparse. We present our experience with interventional PVL closure at our site.

METHODS AND RESULTS

From 08/2014 to 10/2016 ten patients (three women, seven men) at high surgical risk for repeat surgery underwent interventional PVL closure for severe paravalvular regurgitation (PVR) in 14 procedures at our site. Nine procedures (64%) were performed for mitral PVLs, five procedures were performed for aortic PVLs (36%). Mean age of the population treated was 70 ± 8.6 years and mean log. Euro-Score I was 27.4 ± 14.9%. All patients were treated by implantation of Amplatzer Vascular Plug III occluders. All aortic PVLs were treated using a retrograde transfemoral access, mitral PVLs were treated using either a transseptal (8/9) or transapical access (1/9) under 3-dimensional transesophageal echocardiographic and fluoroscopic guidance. Indication for PVL closure was the presence of severe heart failure symptoms in all patients (NYHA class III/IV, n = 14) and additional mechanical hemolytic anemia (n = 5) with a need for transfusion. Interventional closure of PVL was completely successful in 12 procedures (85%), partially successful in one procedure due to inability to cross the defect with a wire (7.5%) and failed in one of 14 procedures due to inability of plug deployment in a very large defect (7.5%). One patient in a critical clinical condition died within 24 h after procedure due to progressive cardiogenic shock after procedural failure and refusal of a surgical treatment by cardiac surgeons. After interventional treatment clinical success with improvement in NYHA functional class or hemolysis was achieved in 93% (13/14). Median NYHA class improved significantly from 4 prior to procedure to 2 after PVL closure (p = 0.0005). Severe PVR was significantly reduced to mild in six patients and to moderate in three patients after procedure (p = 0.001). Complications included one hemothorax after transapical access and one pseudoaneurysm after transfemoral arterial access. In-hospital mortality rate was 20% (2/10) in this high-risk population. After hospital discharge no death occurred during 30-day follow-up, one patient died during 1-year follow-up after PVL closure.

CONCLUSION

In this single-center series interventional PVL closure appears promising for patients at high surgical risk with symptomatic paravalvular regurgitation. Gaining experience in interventional PVL closure at specialized sites will further improve safety and efficacy of this relatively new treatment option. All patients should be treated within large clinical registries to gain more data on mid- and long-term efficacy of transcatheter PVL closure.

Role of Echocardiography in the Diagnosis of Aorto-Right Ventricular Fistula: A Rare Complication of Surgical Aortic Valve Replacement Successfully Closed by Bovine Pericardial Patch

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AoRV fistula is a rare complication of prosthetic aortic valve replacement.

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A high index of suspicion is required for detection.

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Postprocedural follow-up with echocardiography is key to early diagnosis.

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Repair is eventually required if cardiac decompensation ensues.

Percutaneous closure of periprosthetic paravalvular leaks: A viable alternative to surgery?

INTRODUCTION AND OBJECTIVES

Paravalvular leak (PVL) is a possible complication after prosthetic valve implantation. PVL can cause significant symptoms of congestive heart failure and/or hemolysis. Medical therapy is palliative and reoperation has a high mortality rate. Percutaneous transcatheter closure is a promising alternative for symptomatic patients at high surgical risk. We aim to review the efficacy and safety of percutaneous PVL closure in a consecutive series of patients referred to our center.

METHODS

We performed a retrospective analysis of clinical and technical procedural data of patients referred to our center for percutaneous PVL closure between January 2009 and November 2015.

RESULTS

Twenty procedures were performed in 18 patients under general anesthesia and under transesophageal echocardiographic and radiographic guidance. Fourteen mitral PVLs were successfully treated in 13 patients and one aortic PVL in one patient. Most (eight) of the PVLs closed were in mitral bioprostheses. Two patients underwent a second intervention, which was technically successful in one. Technical success was achieved in 15 (75%) of the procedures. At discharge, median NYHA functional class decreased by one and hemolytic anemia decreased from seven cases (38.9%) to two (11.1%). Two patients had minor bleeding at the femoral vascular access site. Survival rates at six, 12 and 24 months were 77.8%, 77.8% and 61.1%, respectively.

CONCLUSIONS

In our experience, percutaneous PVL closure was overall effective and safe. The procedure is complex and a second intervention may be necessary. Percutaneous PVL closure may be a feasible alternative for selected symptomatic patients at high surgical risk refractory to medical therapy.

Percutaneous Closure of 2 Paravalvular Leaks and a Gerbode Defect after Mitral Valve Replacement for Infective Endocarditis

Surgical valve replacement after infective endocarditis can result in local destructive paravalvular lesions. A 30-year-old woman with infective endocarditis underwent mitral valve replacement that was complicated postoperatively by 2 paravalvular leaks. During percutaneous closure of the leaks, a Gerbode defect was also found and closed. We discuss our patient's case and its relation to others in the relevant medical literature. To our knowledge, we are the first to describe the use of a percutaneous approach to close concomitant paravalvular leaks and a Gerbode defect.

Transcatheter paravalvular leak closure and hemolysis - a prospective registry

INTRODUCTION

Paravalvular leak (PVL) related to a surgical prosthetic valve may be associated with clinically significant hemolysis. The influence of transcatheter PVL closure (TPVLC) on hemolysis remains uncertain.

MATERIAL AND METHODS

The prospective registry included patients undergoing TPVLC due to PVL-related heart failure and/or hemolysis. Procedural data, laboratory markers of hemolysis and heart failure status were recorded at baseline, discharge and at 1- and 6-month follow-up.

RESULTS

Of 116 patients from all those qualified for TPVLC, 79 fulfilled the inclusion/exclusion criteria. Hemolysis was significantly more frequent in patients with mitral location of PVL and with calcifications in its channel. After TPVLC prompt reduction of lactate dehydrogenase activity (617.0 (342.0-899.0) vs. 397 (310.0-480.5) IU/l, p < 0.05) and gradual resolution of anemia (hemoglobin (HGB) 11.7 (10.4-13.8) vs. 13.4 (12.9-13.8) g%, p < 0.05) over 6 months were noted. Effective closure of PVL (> 90% reduction of PVL cross-sectional area) resulted in a more prominent increase of red blood cell count and HGB than in patients with residual regurgitation. The TPVLC-related exacerbation of hemolysis was recorded in 14 patients. Its risk was aggravated by presence of significant hemolysis at baseline or residual flow either by a partially uncovered channel or across the occluder. Reduction of hemolysis after successful TPVLC was sustained in 6-month follow-up.

CONCLUSIONS

Risk factors for PVL-related hemolysis were the presence of calcifications in the defect and mitral location of PVL. The TPVLC effectively reduced hemolysis if at least 90% reduction of PVL cross sectional area was achieved. The effect was sustained in 6-month follow-up. Incomplete closure of PVL may increase the magnitude of hemolysis after TPVLC, but it occurred rarely.

Unusual Anemias

Many processes lead to anemia. This review covers anemias that are less commonly encountered in the United States. These anemias include hemoglobin defects like thalassemia, bone marrow failure syndromes like aplastic anemia and pure red cell aplasia, and hemolytic processes such as paroxysmal nocturnal hemoglobinuria. The pathogenesis, diagnostic workup, and treatment of these rare anemias are reviewed.

Hopscotch technique: A novel method for percutaneous closure of paravalvular leaks

OBJECTIVES

To describe the feasibility and safety of the Hopscotch Technique, a novel method to close paravalvular leaks.

BACKGROUND

Successful closure of paravalvular leaks requires the complete seal of irregular defects, frequently interrupted by remaining sutures or tissue that converts a large defect into a complex series of contiguous smaller defects. Successful treatment with devices placed in a single space is impossible with constrained appearance and significant residual leak; therefore, new techniques to deploy smaller devices in the correct location are needed.

METHODS

We retrospective analyzed all the patients with mitral PVLs undergoing percutaneous closure with the Hopscotch technique from November 2011 to January 2016.

RESULTS

Sixteen procedures were performed in 15 patients (median age 66-year-old, 67% male, STS 3.9%), most of them with biological prostheses (73%). Mean PVL size was 12.5 mm located in the lateral position. Percutaneous transapical access was the final approach in nine procedures and success of the procedure was achieved in 12. Usually, the technique was performed by 1 Hopscotch crossing/jump; however, complex procedures requiring 2 or 3 crossings were utilized in 4 patients, even possible between aortic and mitral leaks along the aortic-mitral continuity. Residual mitral paravalvular regurgitation of ≤mild was achieved in 93% of procedures.

CONCLUSIONS

The Hopscotch technique is feasible and safety for patients with mitral paravalvular leak when boundaries prevent full device expansion. © 2017 Wiley Periodicals, Inc.

Transcatheter closure of paravalvular leaks: state of the art

Paravalvular leak (PVL) is a serious complication after surgical valve replacement or after transcatheter aortic valve replacement. Approximately 1-5% of PVLs can lead to serious clinical consequences, including congestive heart failure and/or haemolytic anaemia. For years, surgical re-intervention has been considered the treatment of choice for symptomatic patients with PVLs. However, surgical re-intervention is associated with a high risk of morbidity and mortality. Transcatheter PVL (TPVL) closure is a less invasive alternative to surgical re-intervention. The safety and feasibility of TPVL closure has been confirmed in several registries and a meta-analysis.In this review, we discuss the clinical implications and diagnosis of PVLs, technical considerations for TPVL, execution of the procedure and assessment of the results.

Transcatheter Mitral Valve-in-Valve Therapy

Valve-in-valve and valve-in-ring transcatheter mitral valve replacement can be used in for the treatment of inoperable patients with failing mitral surgical bioprosthesis or valve repairs. Preprocedural multi-image evaluation by a heart team must include transthoracic echocardiogram, transesophageal echocardiogram, and cardiac computed tomography angiography (CTA). CTA is used to determine access site (transapical, transseptal, or transatrial), transcatheter valve size, and landing zone. Though complications can occur (ie, valve embolization, bleeding, or vascular complications), this less invasive procedure has a reported success rate of 70% to 100% and is now increasingly used.

Surgical Transapical Approach for Prosthetic Mitral Paravalvular Leak Closure: Early Results

The objective is to demonstrate safety and early clinical results of surgical transapical closure of paravalvular leaks (PVLs) following mitral valve replacement in significant regurgitation. Between March 2014 and February 2015, 12 patients (mean age 52.1 ± 6.0 years, 66.6% male) with severe symptomatic mitral PVLs (n = 13) underwent surgical transapical closure procedure through left mini-thoracotomy. All patients were in NYHA functional class III-IV and median logistic EuroSCORE was 24.2 ± 6.4% (range, 13.5-34.6%). Indications were heart failure (n = 10) and symptomatic hemolysis (n = 2) due to severe mitral regurgitation (MR). Amplatzer Vascular Plug-III devices (n = 9) were used for smaller and regular defects; whereas Atrial Septal Defect closure devices (n = 4) were used for larger defects. Technical success was achieved in 10 (83.3%) patients. One (8.5%) patient with 2 + MR was treated medically. A patient with residual 4 + MR underwent re-operation. There was no procedure-related complication including mortality, device migration, embolization, or cardiac laceration. Mean procedure and fluoroscopy times were 166.4 ± 39.5 (range, 90-210) and 25.7 ± 17.3 (range, 16-64) minutes, respectively. The mean intensive care and hospital stays were 2.1 ± 1.3 and 10.3 ± 6.5 days, respectively. Clinical efficacy was achieved in 9 (75%) of 12 patients at early follow-up of 8.5 ± 2.1 months. NYHA status was class II in two patients, and no hemolytic anemia was diagnosed. Echocardiographic studies revealed a significant reduction of preoperative MR (3-4+) to less than 1+ MR after operations (P < 0.05). Surgical transapical approach to PVL closure is a safe and effective procedure following mitral valve replacement. Early results show that this procedure can be an alternative to re-operation for high-risk patients. Further studies are needed to prove its effectiveness in the long term.

Subacute left ventricular outflow tract obstruction after transapical closure of a mitral paravalvular leak in the region of the aortomitral curtain

We report a rare case of progressive left ventricular outflow tract (LVOT) obstruction after percutaneous device closure of a mechanical prosthetic mitral valve (MV) paravalvular leak (PVL) in the region of aortomitral curtain in a patient who also had small mechanical aortic valve prosthesis with patient-prosthesis mismatch.

Two-Year Follow Up After Surgical Versus Percutaneous Paravalvular Leak Closure: A Non-Randomized Analysis

BACKGROUND

Percutaneous closure of paravalvular leak (PVL) has emerged as an alternative treatment. Predictors of survival and procedural success are unknown.

OBJECTIVES

To review our experience in the treatment of PVL and evaluate efficacy, mortality, predictors of success, and outcomes.

METHODS

Retrospective review of percutaneous PVL procedures between years 2008 and 2014. Survival and results were compared with a control cohort of surgical patients.

RESULTS

Percutaneous closure was attempted in 51 patients. The surgical group had 36 patients. Defects were perimitral in 67 patients (77%). Mean follow-up (FU) was 784.5 days. After propensity score analysis in-hospital mortality was higher in the surgical group (30.6% vs. 9.8%, OR 6, P 0.01). Clinical improvement was higher in the percutaneous group (71.4% vs. 36.4%, P 0.002). Multivariate analysis showed normal creatinine (OR 15, P < 0.001) as independent predictor of clinical improvement. For the composite end-point of all-cause mortality or readmission, older age (OR 10.7, P 0.001), renal failure, (OR 18, P < 0.01), poor functional class and the absence of clinical improvement (OR 3.9, P < 0.001) were related with a higher risk. There were no differences in survival free from the composite end-point according to the treatment received (surgical or percutaneous).

CONCLUSION

Percutaneous PVL closure has a reasonable rate of success and low complication rates, and results compare favorably with surgical treatment. Older patients and those with poor functional class or renal failure (RF) showed a worse prognosis even after a successful closure. © 2016 Wiley Periodicals, Inc.

Percutaneous transcatheter closure of mitral paravalvular leak via transarterial retrograde approach

Repeat surgery has usually been considered the first choice to solve paravalvular leaks of prosthetic valves, but it carries a high operative risk, a high mortality rate and an increased risk for re-leaks. Percutaneous closure of such defects is possible, and different approaches and devices are used for this purpose. For mitral paravalvular leaks, constructing an arterio-venous wire loop for delivering the closure device through an antegrade approach is the most commonly used technique. Transcatheter closure can also be performed through a transapical approach or retrograde transfemoral arterial approach. We present a case of 68-year-old man with a mitral paravalvular leak that was successfully closed using an Amplatzer^® Duct Occluder II, via retrograde transfemoral arterial approach under three-dimensional transesophageal echocardiographic guidance, without the use of a wire loop. The initial attempt to cross the paravalvular defect was unsuccessful, but the obstacle was finally overcome by introducing complex interventional techniques.

In vitro hemodynamic testing of Amplatzer plugs for paravalvular leak occlusion after transcatheter aortic valve implantation

OBJECTIVE

We aimed to in-vitro test Amplatzer devices (Amplatzer Vascular Plug II and Amplatzer Vascular Plug III, SJM, St. Paul, MN) in closing PVL generated by transcatheter balloon expandable aortic valve prosthesis in order to quantify the effective treatment of PVL.

BACKGROUND

Transcatheter aortic valve implantation (TAVI) procedures represent the treatment of choice for high risk patients. Despite evolving technologies paravalvular leak (PVL) is still a major unaddressed issue. This severe complication significantly impairs long-term survival. Percutaneous treatment of this complication is usually performed with the implantation of not specifically designed and not approved vascular devices.

METHODS

A 26 mm Sapien XT (Edwards Lifesciences, Irvine, CA) was implanted in a rubber aortic root and a semi-elliptical shape PVL was created. The vascular occluder devices were implanted in the PVL and hemodynamic performance was tested in a pulse duplicator according to international standard ISO 5840-3:2013. Different type of comparison tests together with high speed camera recording allowed us to define the global efficiency of the occluders and their interaction with the transcatheter prosthesis.

RESULTS

The results revealed that the use of vascular plugs was not per se sufficient to produce an effective or substantial reduction of PVL with a maximum efficiency of less than 50%. Recorded video showed clearly that the vascular plug always interfered with the leaflet of the prosthetic valve.

CONCLUSIONS

Currently used devices do not guarantee effective treatment of PVL and may otherwise compromise the structural integrity of the prosthetic valve implanted. Specifically designed devices are required.

CONDENSED ABSTRACT

Despite evolving technologies, paravalvular leak (PVL) is still a major unaddressed issue after transcatheter aortic valve implantation. Percutaneous treatment of this complication is usually performed with the implantation of Amplatzer devices not specifically designed and not approved for this specific use. We tested Amplatzer devices in a pulse duplicator to occlude PVL generated after implantation of a 26 mm SAPIENT XT prosthesis. The results revealed that the use of vascular plugs was not per se sufficient to produce an effective or substantial reduction of PVL. The video showed clearly that the vascular plug always interfered with the leaflet of the prosthetic valve.

Device closure of periprosthetic paravalvular regurgitation

Periprosthetic paravalvular regurgitation is an important sequel associated with prosthetic valves whether implanted surgically or via transcatheter approach. They can remain clinically silent or manifest as clinical heart failure, intravascular hemolysis or a combination of both. Periprosthetic defects are becoming increasingly recognized as a source of morbidity and mortality in patients with prosthetic heart valves and in the last few years, the management of this condition has evolved. This review aims to address the current knowledge on the pathophysiology, imaging modalities and management of these defects. It further details the principles, methodology and outcomes of catheter-based device therapy of periprosthetic paravalvular defects.

Percutaneous Closure of an Aortic Prosthetic Paravalvular Leak with Device in a Patient Presenting with Heart Failure

Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valve replacement. Perivalvular prosthetic regurgitation causes significant morbidity and is associated with high perioperative mortality if open surgical repair is required. PVLs manifest with symptoms of congestive heart failure, hemolysis, or in most cases, the combination of both. In recent years, the development of imaging and device techniques significantly shortened the duration of fluoroscopy and procedure success was achieved. Percutaneous transcatheter closure of PVLs with a specific device causes symptomatic improvement. We present a case of transcatheter closure of aortic paravalvular insufficiency with amplatzer duct occluder 2 device.

[Catheter-based closure of paravalvular leaks: "Plug the hole"]

Paravalvular leak (PVL) is a relatively rare, but serious complication occurring in up to 10% of patients after prosthetic aortic valve replacement and in up to 17% of patients after prosthetic mitral valve replacement. Up to 5% of patients will present with symptoms of congestive heart failure or mechanical haemolytic anaemia due to PVL and need further surgical or interventional treatment. Surgical repair is often technically challenging and carries a high mortality and morbidity risk. Catheter-based closure of PVL has emerged as an alternative approach especially for patients with relevant comorbidities at high surgical risk. Interventional closure of PVL is a complex procedure, which needs to be performed by an experienced team of interventional cardiologist, echocardiographer and anesthesiologist. To date available clinical results are promising showing low complication rates and high technical or clinical success rates of catheter-based closure of PVL (60-90%). Compared to surgical closure of PVL lower mortality rates (30-days mortality rate: 4,6%) have been documented in patients treated by catheter-based closure of PVL in clinical practice. Therefore interventional closure seems to be a promising option, which need to be discussed with every symptomatic patient suffering from PVL prior to therapeutical decision making. To date only sparse clinical data is available regarding indication and clinical outcome of patients undergoing catheter-based PVL in clinical practice. Therefore interventional closure of PVL should be limited to experienced interventional cardiologist at present. All patients treated should further be enrolled into a clinical registry to evaluate the safety and efficacy of catheter-based closure of PVL in clinical practice.

Usefulness of three-dimensional transesophageal echocardiography in retrieval of a dislodged vascular plug used to close paraprosthetic mitral regurgitation

In this report, we describe a case of periprocedural dislodgement of an Amplatzer Vascular Plug II device during percutaneous closure of severe paraprosthetic mitral regurgitation. The free plug in the left atrium was successfully retrieved percutaneously using a snare inserted through a sheath under live/real time three-dimensional transesophageal echocardiographic guidance. This proved crucial not only in guiding device deployment but also in detecting and helping management of complications.

A Quick Guide to Paravalvular Leak Closure

Paravalvular leak (PVL) is a seldomly covered aspect of structural heart disease. However, this is a condition that frequently presents after valvular replacement. This article will cover the diagnosising and treating PVL (i.e. imaging, access, and device selection). In addition, specific aspects of aortic and mitral PVL closure will be covered in this review.

Immediate and mid-term clinical course after percutaneous closure of paravalvular leakage

INTRODUCTION AND OBJECTIVES

Percutaneous closure of paravalvular leakage is an alternative to surgery in high-risk patients, but its use has been limited by a lack of specific devices. More appropriate devices-like the Amplatzer Vascular Plug III-have recently been developed, but information about their efficacy and safety is still scarce. The objective of the present study was to assess the mid-term results of paravalvular leakage closure with this device.

METHODS

We analyzed the clinical and echocardiographic course both in-hospital and mid-term (13 [9] months) in a series of 20 consecutive patients (age, 68 years; logistic EuroSCORE, 29) with paravalvular leakage and attempted percutaneous closure.

RESULTS

Closure was attempted for 23 leaks (17 mitral and 6 aortic) during 22 procedures in 20 patients. Implantation was successful in 87% of the leaks and the procedure was successful in 83%-with success being defined as a reduction in regurgitation of ≥ 1 degree. Survival at 1 year was 64.7% and survival free of the composite event of death/surgery was 58.8%. The degree of residual regurgitation was not associated with mortality but was associated with functional status. Survivors showed significant improvement in functional class.

CONCLUSIONS

Percutaneous closure of leakage with the Amplatzer Vascular Plug III is safe and efficient in the mid-term. However, mortality among high-risk patients is high independently of the degree of residual regurgitation, indicating that these procedures are performed when heart disease has reached an advanced stage.