Surgery Insight: percutaneous treatment of prosthetic paravalvular leaks

Access path angle in transapical aortic valve replacement: risk factor for paravalvular leakage

BACKGROUND

The aim of this study was to analyze the angle between the left ventricular (LV) long axis and the LV outflow tract (αLV-LVOT) on cardiac computed tomography and to describe its effect on the occurrence of paravalvular leakage (PL), fluoroscopy time, and postoperative creatine kinase-MB levels in transapical transcatheter aortic valve replacement (TA-TAVR).

METHODS

High-risk patients with severe aortic stenosis scheduled for TA-TAVR using an Edwards SAPIEN (Edwards Lifesciences, Irvine, CA) prosthesis were retrospectively included. The αLV-LVOT was measured during systole and diastole as far as retrospectively gated data sets were available. The αLV-LVOT was correlated with the occurrence of PL, total fluoroscopy time, and postoperative creatine kinase-MB levels. Interobserver variability was assessed in all cases.

RESULTS

The study included 81 patients (57 women [70.4%], 24 men [29.6%]) with an average age of 81.9±5.8 years. The mean αLV-LVOTs were 61.8±9.9 degrees during systole and 61.1±10.0 degrees during diastole. There was a minimal, nonsignificant change in the αLV-LVOT between systole and diastole of 0.2±4.1 degrees (p=0.7). PL was found in 39 patients: grade 0 in 42 (51.9%), grade I in 30 (37.0%), and grade II in 9 (11.1%). Patients with a clinically significant PL (grade≥II) showed a significantly greater mean αLV-LVOT than patients with grade I or without PL (mean difference, 13.8±3.2 degrees; p<0.001). No significant correlation was found between the αLV-LVOT and total fluoroscopy time (r=-0.17, p=0.16) and postoperative creatine kinase-MB levels (r=-0.1, p=0.44).

CONCLUSIONS

During TA-TAVR, greater αLV-LVOTs were associated with significantly higher grades of PL. Thus, the αLV-LVOT might influence the selection of the transapical implantation path and could have a significant effect on designs for future stents or novel delivery devices.

Paravalvular leak after mechanical aortic valve replacement causing hemolytic anemia: closure with vascular plug

: We report a case of a 79-year-old man with hemolytic anemia caused by a small paravalvular leak after aortic valve replacement with mechanical prosthesis. The defect was successfully treated with a vascular plug.

A case demonstrating a percutaneous closure using the amplatzer duct occluder for paravalvular leakage after tricuspid valve replacement

There has been a dramatic increase in the number and type of procedures performed in the field of cardiac intervention in the past decade. Percutaneous intervention is becoming an increasingly recognized modality for the management of prosthetic paravalvular leakages (PVLs) in severely symptomatic non-surgical candidates. Herein, we report our experience of percutaneous closure using the Amplatzer duct occluder for a PVL in a patient who underwent tricuspid valve replacement.

Minimally invasive surgery for aortic stenosis in the geriatric patient: where are we now?

Minimally invasive aortic valve surgery has evolved with time and become the routine approach for aortic surgery in select surgical centers. The success of these procedures in the nonelderly has led some to embark on using minimal access techniques in the geriatric population as well. With the geriatric community often inflicted with the greatest disease burden, suffering not only from a valvular process but also cumulative comorbidities, geriatric patients may be the patients most likely to derive benefit from a minimally invasive approach. Alternative therapies for symptomatic aortic stenosis include conventional full-sternotomy aortic valve replacement in addition to transcatheter aortic valve implantation. Each option has its advantages and disadvantages. The role of minimal access aortic valve surgery and its impact on the progressively aging population in the face of conventional surgery and transcatheter technology is discussed.

Percutaneous closure of an aortic prosthetic paravalvar leak: an Australian first

Percutaneous intervention is becoming an increasingly recognised modality for the management of prosthetic paravalvar leaks (PVLs) with particular utility in severely symptomatic non-surgical candidates. To date, application of this intervention has predominantly involved closure of mitral valve PVLs. Consequently, current literature on its application to aortic PVLs is limited. This article describes what we believe to be the first percutaneous closure of an aortic prosthetic PVL in Australia.

Two-stage percutaneous closure of mitral periprosthetic valvular leak

Periprosthetic valve leak can develop as a complication of valve replacement surgery and may manifest as symptomatic valvular regurgitation, heart failure, or haemolysis. We report a case of severe mitral periprosthetic valve leak requiring a two-stage percutaneous closure technique with multiple Amplatzer® III vascular plugs.

Utility of three-dimensional echocardiography in percutaneous closure of paravalvular leak

The images and videos presented in this case report demonstrate the utility of live three-dimensional (3D) transoesophageal echocardiography (TEE) in guiding the percutaneous closure of paravalvular leak (PVL). This method provides high-quality real time assistance for transseptal puncture and deployment of the closure device through the PVL.