Paravalvular Leak in Structural Heart Disease

Structures on the ventricular side of the prosthetic valve in extremely late mitral paravalvular leak: a case report

Background

Mechanisms of paravalvular leak (PVL) after mitral valve replacement have not been fully delineated. Herein, we report a case of structures on the ventricular side of the mitral valve in a patient with an extremely late PVL.

Case summary

A 68-year-old female underwent aortic and mitral valve replacement with a mechanical valve 29 years ago. She was in good health for 28 years. However, exertional dyspnoea appeared 8 months ago. She was admitted to our hospital for congestive heart failure and haemolytic anaemia. Echocardiography showed severe regurgitation due to PVL of the mitral valve. The fluoroscopy showed that a circular calcification was found below the mitral prosthesis. The operation was performed through a median sternotomy. After the aortic cross-clamp, the aortic mechanical valve was removed. The ventricular side of the mitral valve was inspected with the endoscope through the aortic annulus before manoeuvers were performed in the mitral valve. A gap was seen between the prosthetic valve and annular tissue and subvalvular calcification. A bioprosthetic valve was placed with a modified collar-reinforcement technique using a xenopericardium strip. The postoperative course was uneventful. PVL and haemolysis completely disappeared.

Discussion

The ventricular side of the prosthetic valve could be observed before the mitral valve was removed. Not only the protruding circular calcification and displacement of the prosthetic valve to the atrial side but also the loss of adhesion and adhesive nature of the annular tissue played a definitive role in the late PVL occurrence and recurrence after percutaneous or surgical repair.

The management of paravalvular leaks post aortic valve replacement

BACKGROUND

Paravalvular leak (PVL) is uncommon but can lead to severe complications after surgical or transcatheter aortic valve implantation. Conditions associated with PVLs such as heart failure, hemolysis, and infective endocarditis can lead to catastrophic results if not treated promptly; the therapeutic goals differ according to the presentation. It is vital that PVLs are diagnosed early using various imaging modalities. Different approaches have been studied in managing PVLs; there is an increased interest in the transcatheter aortic valve closure procedure as it is minimally invasive and decreases the occurrence of further reinterventions.

AIM

To discuss the classification of PVLs, diagnostic approaches, and available management options.

METHOD

A literature review was performed using 28 studies.

RESULTS

This review evaluated the relationship between the time of diagnosis, management of PVL and the resulting outcomes.

DISCUSSION

Patients with PVL should be assessed through a multidisciplinary team approach and a patient-selective plan should be in place.

CONCLUSION

Open surgical intervention is reserved for complex cases where minimally invasive techniques cannot be utilized.

Transcatheter closure of multiple paravalvular leaks by a transapical approach under echocardiographic guidance: A case report

CASE SUMMARY

A patient who underwent mechanical aortic and mitral valve replacement developed three paravalvular leaks 10 months later. We located the tracks by puncturing the apex cordis under transoesophageal echocardiography guidance alone and puncturing the femoral artery guided by fluoroscopy. Three paravalvular leaks were occluded with a hybridization method simultaneously. The patient was followed up for 24 months and maintained a good condition.

CONCLUSION

Multiple paravalvular leaks after double valve replacement can be occluded in patients by the use of different approaches under echocardiographic guidance alone.

Update in Paravalvular Leak Closure

PURPOSE OF REVIEW

Given the low occurrence of clinically important paravalvular leak (PVL), there are no large registries or trials in this space to investigate management strategies. This review integrates newer evidence, particularly in imaging guidance for these complex procedures, novel techniques and approaches that our group has taken, as well as approaches to more complex PVL plugging reported in case reports.

RECENT FINDINGS

Perhaps the largest area of growth in the management of PVL is the use of advanced imaging in both pre-procedure evaluation and intra-procedural guidance with gated cardiac CT, 3D TEE, and fluoroscopy fusion technologies. Outside the USA, a new device, the Occlutech PLD, has become available with early data indicating high success rates. There remains little randomized data to support the efficacy of percutaneous PVL closure. Gated cardiac CT has become key to the pre-procedure evaluation for transcatheter closure as it allows for increased procedural efficiency and more accurate pre-procedure planning, particularly when combined with 3D printing. Intra-procedural TEE-fluoro fusion allows for more rapid crossing of defects by providing a visual target for interventionalists. The advent of purpose-built devices for PVL closure may further increase the efficacy and efficiency of percutaneous closure, but significant barriers remain for approval of these devices in the USA.

Diastolic blood pressure predicts outcomes after aortic paravalvular leak closure

OBJECTIVES

We sought to determine hemodynamic effects of aortic paravalvular leak (PVL) and predictors of clinical outcomes after aortic PVL closure.

BACKGROUND

The significance of hemodynamic alterations in PVL and relation to severity, procedural success of percutaneous closure and clinical outcomes have not been defined.

METHODS

Patients undergoing percutaneous PVL closure between July 21, 2004 and September 10, 2018 were included. PVL severity was assessed by echocardiography and aortic angiography. Hemodynamics were assessed by intra-arterial pressure tracings before and after PVL closure. The primary outcome was a composite of mortality, redo aortic valve replacement (AVR) and redo PVL closure.

RESULTS

One hundred and seventeen patients (mean age 70.3 ± 14.9 years, 79% surgical and 21% transcatheter prostheses) underwent PVL closure with 94% technical success. PVL was moderate or greater in 106 (91%) at baseline and 11 (11%) post-procedure. Diastolic BP for those with moderate or greater PVL was lower than for those with less PVL (50.3 ± 11.7 vs. 56.5 ± 12.4 mmHg, p < .001). Pulse pressure was similar between these groups (69.9 ± 20.3 vs. 67.4 ± 21.2 mmHg, p = .39). 35 patients (34%) had 40 events during a mean follow-up of 1.6 ± 1.9 years (23 deaths, 12 redo AVR, and five redo PVL closures). In a multivariate model, final diastolic BP <47 mmHg (HR 3.27 [1.45-7.36], p = .007) was a significant predictor of the composite endpoint.

CONCLUSIONS

Diastolic BP was significantly associated with aortic PVL severity and clinical outcomes after PVL closure. In contrast, pulse pressure did not correlate with PVL severity or outcomes. These findings have implications for clinical management of patients with aortic PVL.

Valve-in-valve transcatheter aortic valve replacement to treat multijet paravalvular regurgitation: A case series and review

Treatment advances for severe symptomatic aortic stenosis including transcatheter and open surgical valve replacement have improved patient survival, length of stay, and speed to recovery. However, paravalvular regurgitation (PVR) is occasionally seen and when moderate or greater in severity is associated with an at least 2-fold increase in 1 year mortality. While several treatment approaches focused on single-jet PVR have been described in the literature, few reports describe multijet PVR. Multijet PVR can successfully be treated with a variety of catheter-based options including valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR). We present two patients with at least moderate PVR following aortic valve replacement who were successfully treated with ViV TAVR along with a review of literature highlighting our rationale for utilizing each management approach. Multijet PVR can be treated successfully with ViV TAVR, but additional options such as self-expanding occluder devices and bioprosthetic valve fracture have a role as adjunctive treatments to achieve optimal results. The etiology of multijet PVR can differ between patients, this heterogeneity underscores the paucity of data to guide treatment strategies. Therefore, successful treatment of multijet PVR requires familiarity with available therapeutic options to achieve optimal results and, by extension, decrease patient mortality.

Paravalvular Leak Assessment: Challenges in Assessing Severity and Interventional Approaches

PURPOSE OF REVIEW

With increasing use of prosthetic valves to treat degenerative valvular heart disease (VHD) in an aging population, the incidence and adverse consequences of paravalvular leaks (PVL) are better recognized. The present work aims to provide a cohesive review of the available literature in order to better guide the evaluation and management of PVL.

RECENT FINDINGS

Despite gains in operator experience and design innovation, significant PVL remains a significant complication that may present with congestive heart failure and/or hemolytic anemia. To date, clear consensus or guidelines on the evaluation and management of PVL remain lacking. Although the evolution of transcatheter valve therapies has had a tremendous impact on the management of patients with VHD, the limitations and complications of such techniques, including PVL, present further challenges. Incidence of PVL, graded as moderate or greater, ranges from 4 to 7.4% in surgical and transcatheter valve replacements, respectively. Improved imaging modalities and the advent of novel surgical and percutaneous therapies have undoubtedly yielded a better understanding of PVL including its anatomical location, mechanism, severity, and treatment options. Echocardiography, used in conjunction with cardiac computed tomography and cardiac magnetic resonance, provides essential details for diagnosis and management of PVL. Transcatheter intervention has become a favored approach in lieu of surgical intervention in select patients after previous surgical or percutaneous valve replacement. PVL treatment with vascular plugs, balloon post-dilation, and the valve-in-valve methods have shown technical success with promising clinical outcomes in appropriately selected patients.

Hemodynamics rounds: Hemodynamics of mitral valve interventions

Mitral valvulopathy presents as regurgitation, stenosis, or mixed disease and can occur in both native and prosthetic valves. Such disease develops in conjunction with pathophysiologic changes in the left atrium (LA) and drives changes in LA compliance, pressure, and thus clinical syndromes. With advances in the understanding and treatment of structural heart disease and in the setting of higher-risk patient populations, less-invasive transcatheter approaches have become increasingly commonplace in the treatment of mitral valve disease. Over time, transcatheter mitral valve interventions have evolved to include paravalvular leak closure, mitral valve repair, and mitral valve replacement. Parallel to this evolution, advances in invasive intracardiac pressure monitoring, particularly at the level of the LA, have also occurred. These advances emphasize the unique interplay between mitral valve disease and LA function; account for limitations of noninvasive assessment; and guide beneficial outcomes in each area of transcatheter mitral valve intervention. As a result, continuous transseptal LA pressure monitoring has developed into an indispensable instrument in successful percutaneous mitral valve intervention, complementing traditional noninvasive assessment.

Use of Intracardiac Echocardiography to Differentiate Post–Transcatheter Aortic Valve Replacement Valve Insufficiency Masquerading as Paravalvular Leak

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TAVR has become a prevalent procedure.

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PVL is a complication of TAVR with increased risk for mortality.

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TEE, TTE, and angiography may misrepresent TAVR eccentric regurgitation for PVL.

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ICE may be used to distinguish TAVR regurgitation.

Aortic Paravalvular Leak Repair: Can TAVR Be the Answer?

A 71-year-old male with endocarditis mediated severe paravalvular leak and nonischemic cardiomyopathy underwent percutaneous repair attempts with a closure device followed by valve-in-valve transcatheter aortic replacement procedure. The case was complicated by cardiac arrest requiring hemodynamic support with Impella placement and secondary iatrogenic central aortic insufficiency requiring further intervention. (Level of Difficulty: Beginner.)

CT support of cardiac structural interventions

Due to its high temporal and isotropic spatial resolution, CT has become firmly established for pre-procedural imaging in the context of structural heart disease interventions. CT allows to very exactly measure dimensions of the target structure, CT can provide information regarding the access route and, as a very valuable addition, volumetric CT data sets can be used to identify fluoroscopic projection angulations to optimally visualize the target structure and place devices. This review provides an overview of current methods and applications of pre-interventional CT to support adult cardiac interventions including transcatheter aortic valve implantation, percutaneous mitral valve intervention, left atrial appendage occlusion and paravalvular leak closure.