Clinical Outcomes in Patients Undergoing Percutaneous Closure of Periprosthetic Paravalvular Leaks

Long-Term Risk of Hospitalization and Death in Patients With Mechanical Prosthetic Heart Valves

Mechanical prosthetic heart valves (MPHVs) are commonly used for valvular heart disease in patients with a long life expectancy. Few longitudinal data on the specific causes of hospitalization in patients with MPHV are available. We investigated the risk of all-cause hospitalization and mortality in patients with MPHV. We performed a prospective, observational, ongoing study including consecutive patients with MPHVs who were referred to the atherothrombosis outpatient clinic of the Policlinico Umberto I of Rome for the vitamin K antagonist management. Study end points were all-cause, cardiovascular hospitalization, and overall mortality. We included 305 patients with MPHV (38.4% women, median age 60.2 years). The site of MPHV was aortic in 53.5%, mitral in 29.5%, and mitroaortic in 17%. During a median follow-up of 57.3 months, 142 hospitalizations occurred (8.16 per 100 person-years). The most common causes of hospitalization were cardiovascular disease (3.62 per 100 person-years), infections, surgery, and bleeding. The predictors of cardiovascular hospitalization were atrial fibrillation (hazard ratio [HR] 1.75, 95% confidence interval [CI] 1.04 to 2.95, p = 0.035), previous stroke/transient ischemic attack (HR 2.96, 95% CI 1.59 to 5.48, p = 0.001), and peripheral artery disease (HR 2.42, 95% CI 1.09 to 5.36, p = 0.030). During a median follow-up of 97.2 months, 61 deaths occurred (2.43 per 100 person-years). Age was directly associated with the risk of death (HR 1.088, 95% CI 1.054 to 1.122, p <0.001), whereas the time in therapeutic range higher than the median was inversely associated (HR 0.436, 95% CI 0.242 to 0.786, p = 0.006). In conclusion, patients with MPHV had a high incidence of hospitalizations, especially cardiovascular-related. The incidence of death is high; however, it may be decreased by maintaining a good quality of anticoagulation.

Transcatheter mitral paravalvular closure: a single centre experience with techniques and outcomes

BACKGROUND

In patients with symptomatic mitral PVL, successful transcatheter reduction of the PVL to less than mild is associated with significant improvement in short- and midterm survival.

OBJECTIVES

In this study, we present our single-centre, same operators' experience on percutaneous paravalvular leak closure with techniques and outcomes.

METHODS

In this retrospective observational designed study, we retrieved hospital records of patients with a surgical history of mechanical or biological prosthetic valve replacement and who subsequently underwent transcatheter mitral paravalvular leak closure (TMPLC). All procedures were performed by the same operators.

RESULTS

A total of 45 patients with 58 PVDs underwent TMPLC using 60 devices. All patients had moderate or severe mitral paravalvular regurgitation associated with symptomatic HF (15.6%), clinically significant haemolytic anaemia (57.8%) or both (26.7%). The technical success rate was 91.4%, with 53 defects successfully occluded. The clinical success rate was 75.6%. Among the clinical success parameters, the preprocedural median ejection fraction increased from 45% (35-55) to 50% (40-55) (p = .04). Mitral gradients decreased from max/mean 18/8 mmHg to max/mean 16/7 mmHg; p = .02). Haemoglobin levels increased from 9.9 (8.5-11.1) to 11.1 (3-13); p = .003. LDH levels decreased from 875 (556-1125) to 435 (314-579); p: <.001. All-cause 30-day and in-hospital mortality rates were the same at 8.9%.

CONCLUSION

This single-centre study with a limited number of patients confirmed that TMPLC is a safe and effective procedure to improve symptoms and severity of PVL.

Impact of a Successful Percutaneous Mitral Paravalvular Leak Closure on Long-term Major Clinical Outcomes

BACKGROUND

Percutaneous mitral paravalvular leak (PVL) closure techniques are an effective and safe alternative to surgical treatment, but data regarding long-term outcomes are scarce. We aim to describe the impact of successful percutaneous mitral PVL closure on long-term outcomes.

METHODS

All consecutive patients in whom a first-attempt percutaneous mitral PVL closure was performed in a single tertiary centre between January 2010 and October 2021 were included. Clinical variables, procedural details, and procedural success were collected. Patients were classified based on procedural success, defined as no more than mild residual leak. All-cause mortality was the primary endpoint. Cardiovascular death and heart failure hospitalizations (HFHs) were key secondary endpoints.

RESULTS

Ninety patients (median age 72.5 years [66.0-78.4]; median EuroSCORE-II 8.2 [5.3-12.46]) were included. Although reduction of at least 1 degree in PVL severity was achieved in 82 (91.1%), procedural success was achieved in 47 (52.2%). Chronic kidney disease, previous surgery for PVL, and the presence of multiple jets were independently associated with procedural failure. After a median follow-up of 3.2 (1.2-5.2) years, mortality rate was higher in the procedural failure group (27.3 per 100 patients-years) compared with the group with successful closure (8.2 per 100 patient-years). Procedural failure was associated with all-cause death (adjusted hazard ratio [aHR], 2.59; 95% confidence interval [CI], 1.41-4.78), cardiovascular death (aHR, 3.53; 95% CI, 1.67-7.49) and HFH (aHR, 3.27; 95% CI,1.72-6.20).

CONCLUSIONS

A successful reduction in PVL to mild or absent is associated with improved rates of all-cause death, cardiovascular death, and HFHs.

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 or Surgery for Symptomatic Paravalvular Leaks: The Multicenter KISS Registry

BACKGROUND

The optimal treatment of symptomatic paravalvular leak (PVL) remains controversial between transcatheter closure (TC) and surgery. This large-scale study aimed to retrospectively evaluate the long-term outcomes of the patients who underwent reoperation or TC of PVLs.

METHODS AND RESULTS

A total of 335 (men, 209 [62.4%]; mean age, 58.15±12.77 years) patients who underwent treatment of PVL at 3 tertiary centers between January 2002 and December 2021 were included. Echocardiographic features, procedure details, and in-hospital or long-term outcomes were assessed. The primary end point was defined as the all-cause death during follow-up. The regression models were adjusted by applying the inverse probability weighted approach to reduce treatment selection bias. The initial management strategy was TC in 171 (51%) patients and surgery in 164 (49%) cases. Three hundred cases (89.6%) had mitral PVL, and 35 (10.4%) had aortic PVL. The mean left ventricular ejection fraction was 52.03±10.79%. Technical (78.9 versus 76.2%; P=0.549) and procedural success (73.7 versus 65.2%; P=0.093) were similar between both groups. In both univariate and multivariable logistic regression analysis, the in-hospital mortality rate in the overall population was significantly higher (15.9 versus 4.7%) in the surgery group compared with the TC group (unadjusted odds ratio, 3.13 [95% CI, 1.75-5.88]; P=0.001; and adjusted odds ratio (inverse probability-weighted), 4.55 [95% CI, 2.27-10.0]; P<0.001). However, the long-term mortality rate in the overall population did not differ between the surgery group and the TC group (unadjusted hazard ratio [HR], 0.86 [95% CI, 0.59-1.25]; P=0.435; and adjusted HR (inverse probability-weighted), 1.11 [95% CI, 0.67-1.81]; P=0.679).

CONCLUSIONS

The current data suggest that percutaneous closure of PVL was associated with lower early and comparable long-term mortality rates compared with surgery.

Multimodality Imaging for the Assessment of Mitral Valve Disease

Mitral valve disease is the most common valvular heart disease. Imaging determines the etiology (anatomic assessment), valve function and severity of valvular heart disease (hemodynamic assessment), remodeling of the left ventricle and right ventricle, and preplanning and guidance of percutaneous intervention. Although roles of computed tomography and magnetic resonance are increasing, echocardiography serves as the first-line imaging modality for the diagnosis and serial follow-up in most cases. This review summarizes the roles of multimodality imaging currently available from research fields to daily clinical practice.

Contemporary Review of Transcatheter Mitral Valve Interventions for Mitral Regurgitation

Mitral regurgitation (MR) is the most common form of valvular heart disease in the United States, and there are established guidelines for indications for requiring mitral valve surgeries. However, there is an unmet clinical need for a subset of high-risk MR patients, especially those with advanced age, heart failure and/or secondary MR. Following the successes of transcatheter aortic valve replacements, significant advances have occurred over the last decade in transcatheter mitral valve interventions in order to manage these patients in both clinical practice and trials. The three main types of these interventions include a transcatheter edge-to-edge repair, percutaneous mitral annuloplasty (both direct and indirect) and transcatheter mitral valve replacement (including when applied to a prior prosthetic valve, annuloplasty ring and mitral annuloplasty ring). This review aims to discuss the contemporary techniques, evidence, indications, multimodality imaging evaluations and outcomes of the various transcatheter mitral valve interventions.

Correlation of Clinical Outcomes with the Prominent Indication of Transcatheter Paravalvular Leak Closure: A Multicenter Experience

BACKGROUND

A paravalvular leak (PVL) is a complication following valve replacement, which may lead to heart failure and hemolysis. The aim of this study is to investigate whether the clinical outcome after transcatheter PVL closure differs according to the prominent indication of the procedure (symptoms of heart failure or hemolysis).

METHODS

The data of consecutive patients who had transcatheter treatment for PVL between July 2011 and September 2022 in five Greek centers were analyzed. The primary endpoint was the technical, and clinical success rates with regards to the prominent indication of paravalvular leak closure. The secondary endpoints included the evaluation and comparison of the clinical and technical success in relation to the type of valve that was treated (aortic or mitral) as well as the survival analysis in relation to the closure indication and type of valve that was treated.

RESULTS

In total, 60 patients were retrospectively studied (39% men, mean age 69.5 ± 11 years). Regarding the primary outcomes, the technical success in patients mainly suffering from hemolysis was 86.1%, while in those presenting heart failure it was 95.8%, p = 0.387. Furthermore, the clinical success was 72.2% and 87.5% among hemolysis and heart failure patients, respectively, p = 0.210. During the follow-up period, the two-year survival rates were significantly better for patients treated for the aortic valve (78.94%) compared to those in the mitral position (48.78%), p = 0.014. In total, 25 patients died (41.7%) during 24 months of follow-up.

CONCLUSIONS

Transcatheter paravalvular leak closure can be performed with high technical and clinical success rates without any difference according to the prominent indication of closure.

Case report: Stenosis turned leak … and turned stenosis-complications of paravalvular prosthetic leak closure with a plug device

Background

Paravalvular leak is one of the most common complications and is among the most important prognostic factors of short- and long-term mortality after transcatheter aortic valve implantation (TAVI). Percutaneous valvular leak repair constitutes a first-line treatment for paravalvular leaks and is associated with high success rates and few serious complications nowadays. To the best of our knowledge, this is the first case where placement of the device through the stenting of the bioprosthesis resulted in creating a new symptomatic stenosis that required surgery.

Case summary

We present a case of a patient with low-flow, low-gradient aortic stenosis treated with transfemoral implantation of a biological aortic prosthesis. One month after the procedure, the patient presented with acute pulmonary oedema and a paravalvular leak was discovered, which was corrected by percutaneous repair with a plug device. Five weeks after the valvular leak repair, the patient was readmitted for heart failure. At this time, a new aortic stenosis and paravalvular leak were diagnosed and the patient was referred for surgery. The new aortic mixed diseased was caused by the positioning of the plug device through the valve's metal stenting, which resulted in a paravalvular leak and pressed against the valve's leaflets, causing valvular stenosis. The patient was referred for surgical replacement and evolved well afterward.

Conclusion

This case illustrates a rare complication of a complex procedure, and it highlights the need for multidisciplinary decisions and good cooperation between the cardiology and cardiac surgery teams to develop better criteria in the selection of the appropriate technique for managing paravalvular leaks after TAVI.

Intractable Heart Failure From a Severe Mitral Paravalvular Leak in Surgically Created Bipartite Left Atrium

We describe a 38-year-old Middle Eastern woman with a long history of multiple cardiac surgical procedures for mitral valve disease who presented with intractable heart failure from severe mitral paravalvular regurgitation requiring multiple medical admissions since 2019. She was deemed a very high surgical risk and was treated successfully with a percutaneous technique. (Level of Difficulty: Advanced.)

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.

Percutaneous Closure of Mitral Paravalvular Leak: Long-Term Results in a Single-Center Experience

Background: Paravalvular leak occurs in 5–17% of patients following surgical valve replacement, more often in mitral position. The prognosis without treatment is poor. Percutaneous device closure represents an alternative to repeat surgery. The objective of this work is to evaluate the medium and long-term results in the percutaneous closure of PVL in mitral prosthesis. Methods: This observational study is based on a retrospective registry including consecutive mitral PVL cases undergoing percutaneous closure at a single tertiary-care center from April 2010 to December 2020. The safety and efficacy results of the procedure, at 90 days and in the long term, were analyzed. Also, predictors of procedure failure and long-term events were identified. Results: A total of 128 consecutive mitral paravalvular leak closure procedures were included. Technical success was achieved in 115 (89.8%) procedures. The presence of multiple PVLs was the sole factor that independently predicted procedural failure. Median follow-up of our sample was 41.8 months (mean 47.7 ± 35.7 months). Underlying hemolytic anemia as the indication for PVL closure, a recent admission for decompensated HF, and lack of improvement in functional class emerged as consistent predictors of MACE and death during long-term follow-up, while lack of procedural success during the first PVL procedure and chronic kidney disease were also associated with MACE during follow-up. Conclusions: Percutaneous mitral PVL closure displayed high technical and procedural success rates, with an acceptable safety profile, in a high-risk population. Percutaneous mitral PVL closure achieved an improvement in short- and long-term functional class and a reduction of hemolysis in the vast majority of patients. In addition, long-term survival in our study was good, in particular for patients undergoing successful PVL closure procedures.

Transcatheter closure of periprosthetic leaks

Percutaneous paravalvular leak closure represents a small but important niche in structural interventions in the current era of interventional cardiology. It is estimated that paravalvular regurgitation affects 2-17% of all implanted prosthetic heart valves (which equates to 500 to 10,200 cases annually). Patients may present with clinical signs and evidence of heart failure, hemolysis or both. Due to the increased morbidity and mortality, reoperation is often best avoided, especially if the underlying perivalvular tissue is friable or heavily calcified. Perimitral defects are usually approached in an antegrade approach via a transeptal puncture; periaortic defects usually in a retrograde approach. Depending on the number, size and shape of the defect(s) - as determined by 2D and 3D echocardiography as well as 4D computed tomography - one or multiple closure devices are deployed using various wiring and anchor techniques. This brief review provides an updated summary of the currently applied paravalvular leak closure techniques.

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.

EchoNavigator virtual marker and Agilis NxT steerable introducer facilitate transseptal transcatheter closure of mitral paravalvular leak

BACKGROUND

Paravalvular leak (PVL), also known as paravalvular prosthetic regurgitation, is not a rare complication after surgical valve replacement, and it may cause varying degrees of heart failure. The transcatheter closure of PVL is technically demanding and challenging.

CASE SUMMARY

A 68-year-old man presented with degenerative mitral regurgitation with heart failure, New York Heart Association functional class 3. He received bioprosthetic mitral valve replacement in December 2019. PVL was noted at the location of the aorto-mitral curtain in transesophageal echocardiography without signs of endocarditis or dehiscence of the bioprosthetic valve. Transseptal transcatheter closure of the mitral PVL was performed efficiently using the EchoNavigator virtual marker and Agilis NxT steerable introducer.

CONCLUSION

This case highlights that the EchoNavigator virtual marker and Agilis NxT steerable introducer can facilitate transseptal transcatheter closure of mitral PVL by reducing the procedure time and contrast media.

Embolization of a Vascular Plug after a Year and Successful Treatment Using Two Vascular Plugs Side by Side

•

Vascular plugs used for PVL repair usually embolize late after deployment.

•

A low threshold for echo studies (namely TEE) is an essential part of clinical follow-up.

•

Redo percutaneous PVL closure should be considered in those at high surgical risk.

Safety, Efficacy and Long-Term Outcomes of Patients Treated with the Occlutech Paravalvular Leak Device for Significant Paravalvular Regurgitation

Between December 2014 and March 2021, 144 patients with aortic (Ao) or mitral (Mi) paravalvular leaks (PVLs) were enrolled at 21 sites in 10 countries. Safety data were available for 137 patients, who were included in the safety analysis fraction (SAF), 93 patients with Mi PVLs and 44 patients with Ao PVLs. The full analysis set (FAS) comprised 112 patients with available stratum (aortic/mitral leak) as well as baseline (BL), 180-day or later assessments (2 years). Procedural success (implantation of the device with a proper closure of the PVL, defined as reduction in paravalvular regurgitation of ≥one grade as assessed by echocardiography post implantation) was achieved in 91.3% of FAS patients with Mi PVLs and in 90.0% of those with Ao PVLs. The proportion of patients suffering from significant or severe heart failure (HF), classified as New York Heart Association (NYHA) class III/IV, decreased from 80% at baseline to 14.1% at 2-year follow-up (FAS). The proportion of FAS patients needing hemolysis-related blood transfusion decreased from 35.5% to 3.8% and from 8.1% to 0% in Mi patients and Ao patients, respectively. In total, 35 serious adverse events (SAEs) were reported in 27 patients (19.7%) of the SAF population. The SAEs considered possibly or probably related to the device included device embolization (three patients), residual leak (two patients) and vascular complication (one patient). During follow-up, 12/137 (8.8%) patients died, but none of the deaths was considered to be device-related. Patients implanted with the Occlutech Paravalvular Leak Device (PLD) showed long-lasting improvements in clinical parameters, including NYHA class and a reduced dependency on hemolysis-related blood transfusions.

Paravalvular Regurgitation: an Overview of Indications for Closure and Management Strategies

PURPOSE OF REVIEW

Paravalvular leak (PVL) after surgical or transcatheter valve replacement is common, occurring in up to one-third of patients. As a method to avoid open surgery, transcatheter closure of PVL has become an established therapy in selected cases.

RECENT FINDINGS

To facilitate procedural success, baseline comprehensive assessment by echocardiography and cardiac computed tomography (CCT), intraprocedural guidance by echocardiography and fluorography, and appropriate wire rail techniques are essential. We present examples of how to treat challenging PVL cases in the aortic and mitral positions. Although challenging, transcatheter PVL repair is effective and safe for treatment of PVL in selected cases by experienced operators.

Technical Recommendations for Real-Time Echocardiography and Fluoroscopy Imaging Fusion in Catheter-Based Mitral Valve Paravalvular Leak and Other Procedures

Widespread catheter-based interventions for structural heart disease have overtaken the treatment of paravalvular leaks (PVL). Multimodality imaging techniques play a crucial role in accurate diagnosis, procedure planning and performance. However, PVL closure is often technically challenging due to the complex anatomy of the defects and their relation to surrounding anatomical structures. The application of echocardiography and fluoroscopy imaging fusion (EFF) may simplify challenging imaginative three-dimensional reconstruction of the intracardiac anatomy and facilitate the procedure. To master new technology, personnel must make cognitive changes, overcome a learning curve, and obtain adequate theoretical knowledge. Main aim of this manuscript is to present basic recommendations for EFF application in practice, alongside, each scenario is supported by technically challenging clinical examples. We may conclude that our manuscript may provide useful information for physicians on EEF application in clinical practice.

Mitral Paravalvular Leak: Clinical Implications, Diagnosis and Management

Paravalvular leak incidence after mitral surgical replacement ranges from 7% to 17%. Between 1% and 5% of these are clinically significant. Large PVLs can cause important clinical manifestations such as heart failure or haemolysis. Current guidelines consider that surgical reparation is the gold-standard therapy in symptomatic patients with paravalvular leak. However, these recommendations are based in non-randomized observational registries. On the other hand, transcatheter paravalvular leak closure has shown excellent results with a low rate of complications, and nowadays it is considered the first option in selected patients in some experienced centres. In this review, we summarize the clinical manifestations, diagnosis, procedural details, and results of transcatheter mitral PVL closure.

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.

Percutaneous management of paravalvular leaks

Paravalvular leak (PVL) is a challenging complication of valve replacement surgery that can cause heart failure and haemolysis. Surgical repair is the traditional treatment for severe, symptomatic PVL, but many patients with PVL fall into high-risk categories for redo surgery. Percutaneous techniques for closure of PVL have been increasingly refined over the last decade with availability of approved purpose-specific devices for closure. Percutaneous closure requires a heart team approach, with attention paid to appropriate preprocedural and periprocedural imaging to ensure a successful closure with minimal residual leak or complication. There are limited studies addressing the selection of a percutaneous approach to PVL. No randomised trials comparing surgical and percutaneous repair have been conducted. Large national registries from the UK and Ireland and from Spain have demonstrated that high rates of technical success can be achieved, with mortality comparable with surgical repair. Six retrospective studies comparing surgical and percutaneous approaches have been published. These broadly show comparable technical success between the interventions, with reduced short-term mortality among patients treated percutaneously. Long-term outcomes were similar between both treatment options. Percutaneous repair is an attractive treatment option in many patients due to its reduced invasiveness and quicker recovery period. However, more prospective studies are needed to validate its place in the armamentarium of the heart team.

Long-term outcomes of catheter-based intervention for clinically significant paravalvular leak

BACKGROUND

In most centres, clinically significant percutaneous paravalvular leak (PVL) closure following valve replacement surgery is reserved for those considered high-risk for surgery. There is a paucity of data regarding the long-term outcomes of these patients.

AIMS

Our goals were to assess the long-term outcomes of patients undergoing percutaneous PVL closure.

METHODS

A total of 100 consecutive transcatheter PVL closure procedures (74 mitral, 26 aortic) were performed in 95 patients between February 2005 and August 2019 at our hospital. Data collected included procedural success rates, indication-specific outcomes and mortality.

RESULTS

Mean follow-up was 5.6±6.1 years, mean age 62.6±15.2 years, and 45.4% were female. The device was successfully implanted in 88 procedures (88.0%). Patients who presented with heart failure (n=57) had a significant improvement in NYHA classification (29.2% Class III/IV versus 100.0%, p<0.001). For patients who presented with haemolytic anaemia (n=38), haemoglobin increased (11.94±1.634 vs 9.72±1.49, p<0.001) and LDH levels were reduced (1,354.90±1,225.55 vs 2,039.40±1,347.20, p<0.001) following the procedure. Rates of mortality were 3.8% at 90 days, 15.6% after 1 year, and 27.2% after 5 years.

CONCLUSIONS

For patients who are deemed intermediate- to high-risk for repeat surgery, transcatheter PVL closure shows reasonable clinical success rates, with a significant improvement in symptoms, and a relatively low rate of periprocedural complications.

Effect of Eccentric Calcification of an Aortic Valve on the Implant Depth of a Venus-A Prosthesis During Transcatheter Aortic Valve Replacement: A Retrospective Study

Object

Our goal was to assess the implant depth of a Venus-A prosthesis during transcatheter aortic valve replacement (TAVR) when the areas of eccentric calcification were distributed in different sections of the aortic valve.

Methods

A total of 53 patients with eccentric calcification of the aortic valve who underwent TAVR with a Venus-A prosthesis from January 2018 to November 2019 were retrospectively analyzed. The patients were divided into three groups (A, B, and C) according to the location of the eccentric calcification, which was determined by preprocedural computerized tomography angiography (CTA) images. The prosthesis release process and position were evaluated by contrast aortography during TAVR, and the differences in valve implant depths were compared among the three groups. The effects of different aortic root structures and procedural strategies on prosthesis implant depth were analyzed.

Results

Eleven patients had eccentric calcification in region A; 19 patients, in region B; and 23 patients, in region C. The patients with eccentric calcification in region B had a higher risk of prosthesis migration (10.5% upward and 21.1% downward), and the position of the prosthesis after TAVR in group B was the deepest among the three groups. When eccentric calcification was located in region A or C, the prosthesis was released at the standard position with more stability, and the location of the prosthesis was less deep after TAVR (region A: 4.12 ± 3.4 mm; region B: 10.2 ± 5.3 mm; region C: 8.4 ± 4.0 mm; region A vs. region B, P = 0.0004; region C vs. region B; and P = 0.0360). In addition, the left ventricular outflow tract (LVOT) (P = 0.0213) and aortic root angulation (P = 0.0263) also had a significant effect on implant depth in the aortic root structure of the patients. The prosthesis size was 28.3 ± 2.4 in the deep implant group and 26.4 ± 2.0 in the appropriate implant group (P = 0.0068).

Conclusion

The implant depth of the Venus-A prosthesis is closely related to the distribution of eccentric calcification in the aortic valve during TAVR. Surgeons should adjust the surgical strategy according to aortic root morphology to prevent prosthesis migration.

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.

How to Image and Manage Prosthesis-Related Complications After Transcatheter Aortic Valve Replacement

PURPOSE OF REVIEW

In this review, we provide an overview of potential prosthesis - related complications after transcatheter aortic valve replacement, their incidences, the imaging modalities best suited for detection, and possible strategies to manage these complications.

RECENT FINDINGS

Therapy for severe aortic valve stenosis requiring intervention has increasingly evolved toward transcatheter aortic valve replacement over the past decade, and the number of procedures performed has increased steadily in recent years. As more and more centers favor a minimalistic approach and largely dispense with general anesthesia and intra-procedural imaging by transesophageal echocardiography, post-procedural imaging is becoming increasingly important to promptly detect dysfunction of the transcatheter valve and potential complications. Complications after transcatheter aortic valve replacement must be detected immediately in order to initiate adequate therapeutic measures, which require a profound knowledge of possible complications that may occur after transcatheter aortic valve replacement, the imaging modalities best suited for detection, and available treatment options.

Multimodality Imaging for the Assessment of Mitral Valve Disease

Mitral valve disease is the most common valvular heart disease. Imaging determines the etiology (anatomic assessment), valve function and severity of valvular heart disease (hemodynamic assessment), remodeling of the left ventricle and right ventricle, and preplanning and guidance of percutaneous intervention. Although roles of computed tomography and magnetic resonance are increasing, echocardiography serves as the first-line imaging modality for the diagnosis and serial follow-up in most cases. This review summarizes the roles of multimodality imaging currently available from research fields to daily clinical practice.

Transcatheter Closure of Mitral Paravalvular Leak via Multiple Approaches

Objectives

The purpose of this study was to review the experiences with transcatheter closure of mitral PVL after surgical valve replacement.

Background

Transcatheter closure of paravalvular leak (PVL) is an intricate alternative to surgical closure. But it represents one of the most intricate procedures in the field of structural heart interventions, especially for patients with mitral PVL.

Methods

From January 2015 through January 2019, 35 patients with mitral PVL after valve replacement underwent transcatheter closure. We reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up was 26 (3–48) months.

Results

Acute procedural success was achieved in 33/35 (94.3%) patients. Twenty-five patients had single mitral prosthetic valve replacements; 10 had combined aortic and mitral prosthetic valve replacements previously; 28 had mechanical valves; and 7 had bioprosthetic valves. All percutaneous procedures were performed with local anesthesia except for seven transapical cases with general anesthesia. Multiple approaches were used: transfemoral, transapical, and transseptal via an arteriovenous loop. Multiple devices were deployed. There were no hospital deaths. The procedural time was 67–300 (124 ± 62) minutes. Fluoroscopic time was 17–50 (23.6 ± 12.1) minutes. The hospital stay was 5–17 (8.3 ± 3.2) days. Complications included recurrent hemolysis, residual regurgitation, acute renal insufficiency, and anemia. Twenty-seven (77.1%) patients improved by ≥1 New York Heart Association functional class at the 1-year follow-up.

Conclusions

Transcatheter mitral PVL closure requires complex catheter techniques. However, this minimally invasive treatment could provide reliable outcomes and shorter hospital stays in selected patients. This trial is registered with NCT02917980.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Closure of a Prosthetic Mitral Valve Paravalvular Leak Using a Ventricular Septal Defect (VSD) Amplatzer Occluder Device

BACKGROUND Paravalvular leaks (PVL) are becoming more commonly experienced in clinical practice due to the increasing number of mitral valve replacements performed. There are about 182 000 valve replacements performed annually, with a 5-15% prevalence rate of paravalvular leaks. Due to increased mortality associated with surgical repair, percutaneous transcatheter closure procedures are increasingly being performed as an alternative to repeat surgery. CASE REPORT We present the case of a 52-year-old woman with past medical history of mitral valve endocarditis who developed worsening acute heart failure 1 month after surgical bioprosthetic mitral valve replacement. Transesophageal echocardiography at the time revealed dehiscence of the bioprosthetic mitral valve and severe mitral regurgitation. She subsequently had emergent surgical bioprosthetic mitral valve replacement and annular reconstruction. The post-operative course was complicated by increasing dyspnea and lower-extremity edema, with recurrent pericardial tamponade requiring placement of a pericardial window. Based on her multiple comorbidities, most notably the concomitant right ventricular failure with severe pulmonary hypertension and prior pericardial patch repair with compromise of her mitral valve annulus, she was deemed inoperable for re-do surgery and eventually underwent a successful percutaneous closure of the mitral paravalvular leak with a ventricular septal defect (VSD) Amplatzer occluder device. The patient made good recovery and was discharged home a few days after the procedure. CONCLUSIONS Although use of the Amplatzer VSD occluder device for this indication currently remains off-label, our report supports the use of the VSD occluder device in this subset of patients considering the high mortality rates associated with repeat surgical procedure.

A comprehensive review of the diagnosis and management of mitral paravalvular leakage

Mitral paravalvular leaks (PVLs) commonly occur in patients with prosthetic valves. Paravalvular defects may be clinically inconsequential and may aggravate hemolysis or cause heart failure through regurgitation. Accordingly, patients may eventually require intervention such as redo surgery or a transcatheter closure of the defects. The introduction of purpose-specific closure devices and new steerable catheters has opened a new frontier for the transcatheter PVL closure. This mode of treatment is an initial therapy in most centers with experienced structural heart team. However, head-to-head data comparing two treatment modalities (surgery and transcatheter closure) are limited, and the world-wide experience is based on nonrandomized studies. Multimodality imaging, including three-dimensional transesophageal echocardiography, facilitates the delineation of mitral PVLs and provides essential data that aids the communication between the members of the structural heart team. In the near future, the success of interventional therapies will most probably increase in patients with mitral PVLs with the introduction of hybrid imaging modalities (echocardiography, cardiac computed tomography, and fluoroscopy). In conclusion, this paper summarizes the etiopathogenesis, clinical characteristics, diagnosis, and treatment of mitral PVLs. (Anatol J Cardiol 2020; 24: 350-60)

Elective Percutaneous Paravalvular Leak Closure Under Conscious Sedation: Procedural Techniques and Clinical Outcomes

BACKGROUND

Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valves that are detected up to 18% of all implanted surgical valves. Perioperative morbidity is thought to be lower in percutaneous compared to surgical PVL repair. However, a direct comparison of PVL closure techniques has never been performed. Our study is the first to demonstrate that elective PVL closure with monitored anesthesia care can be achieved with high success and low complications rates resulting in short hospital stays.

METHODS

This is a retrospective cohort of patients admitted electively for catheter-based treatment of symptomatic prosthetic paravalvular regurgitation from Jan 2013 to April 2018. Both mitral and aortic PVLs were included. Patients' demographics, risk factors, procedural outcomes, In-hospital and thirty-day mortality were all reported. We followed the Valve Academic Research Consortium (VARC) criteria to define device and procedural technical success. In-hospital and 30- day outcomes were assessed by retrospective chart review.

RESULTS

A total of 54 PVLs in thirty-seven patients were repaired (65% aortic & 35% mitral). The mean-age in the mitral cohort was lower than the aortic cohort (61 vs 72years, P<0.0001) but the two groups shared similar clinical risk factors (P>0.05). Average hospital stay was 1-2days (<1.5days overall cohort) which was significantly lower in the aortic compared to the mitral cohort (P=0.009). All procedures were guided by TEE under conscious sedation with monitored anesthesia care. Procedural technical success defined as any significant residual shunt was 81% in the overall cohort and 88% in the aortic group. No procedural deaths were reported. Short-term mortality during the first 30days was 5.4% (two patients).

CONCLUSION

Elective catheter-based repair of symptomatic prosthetic paravalvular regurgitation appears to be safe and effective. The use of conscious sedation with monitored anesthesia care resulted in short hospital stay.

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.

Paravalvular leak closure with real time transesophageal echocardiography and fluoroscopy fusion

Transcatheter technology has been increasingly used for paravalvular leak closure. We report the use of “Fusion Technology” (EchoNaviagator, Phillips, Tustin, CA) that combines real-time 2 and 3 dimensional trans-esophageal echocardiography with fluoroscopy imaging to facilitate paravalvular leak closure. This could help to identify the exact site, size, depth and shape of the paravalvular leak for proper positioning of the occluder device, which may result in saving time and effort.

Use of RailwayTM Dilator as a Novel Technique to Cross Prosthetic Aortic and Mitral Paravalvular Leak

Percutaneous endovascular repair of prosthetic paravalvular leaks (PVLs) has emerged as a safer, and less invasive option preferred for many patients. Crossing the PVL with a guide catheter (GC), or guide sheath is one of the challenging aspects of this technique and at times require arteriovenous (AV) rail creation. AV rail creation requires additional arterial access, snaring, and externalizing of a wire, all of which are associated with unique challenges and complications risk. Despite using these techniques, nearly 8% of the PVL closure procedures are unsuccessful. We report two cases with a novel technique of using a 0.035″ dilator from the Railway™, a radial sheathless access system, to successfully cross a guide catheter (GC) through difficult PVL when the traditional telescoping technique failed.

Novel Use of Echo Fusion and Cardiac Computed Tomographic Imaging Guidance for Percutaneous Paravalvular Leak Closure

•

Echo fusion overlays echocardiographic cardiac structures over fluoroscopy.

•

Echo fusion provides “real-time” feedback during complicated percutaneous procedures.

•

Echo fusion and 3D TEE imaging can be used to localize PVLs and guide intervention.