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.

[Paravalvular leak closure using off - label devices: a useful resource]

We present the case of a patient with a paravalvular leak of mechanical prosthesis in aortic position. Due to a recent previous surgery, it was decided to perform a percutaneous repair to reduce perioperative risk, under an off-label indication using a device for ventricular septal defect closure, successful and without complications in the follow-up.

Transcatheter para mitral annular ring leak device closure - A case report

Para mitral annular ring leakage can occur following ring dehiscence after mitral annuloplasty. Percutaneous device closure of para-annular ring leakage can be performed successfully to treat such regurgitations with good transesophageal echocardiography guidance and patient selection. While para valvular device closure has been described in the medical literature, there have been few anecdotal reports published on para ring leak device closures. In this case, we highlight our experience from the successful closure of a para mitral annular ring closure with an AVP III device. The patient had a para annular ring regurgitation post coronary artery bypass grafting with mitral ring annuloplasty presenting with hemolytic anemia and acute renal failure, successfully treated by percutaneous device closure.

Learning objective

This report describes the safety and effectiveness of a transcatheter para ring leak closure with an AVP III device. We applied the principles of device closure of paravalvular leak from our experience and related data from literature for this case and describe various hardware and techniques used for a successful closure of a para mitral ring leak.

Left atrial dissection after a supra-annular mitral valve replacement for endocarditis

BACKGROUND

Left atrial dissection is a rare and a potentially fatal complication of cardiac surgery. Multi-modal imagery is helpful for the diagnosis and to guide the treatment.

CASE PRESENTATION

We report the case of a 66-year-old female patient who underwent a combined mitral and aortic valve replacement for degenerative valvular disease. She presented an infectious endocarditis revealed by a third-degree atrioventricular bloc and had a redo mitral- and aortic valve replacement. Mitral valve was inserted in supra-annular position due to annular destruction. Post-operative course was marked by a refractory acute heart failure explained by a left atrial wall dissection confirmed by transoesophageal echocardiography and synchronized cardiac CT-scan. Surgical treatment was theoretically indicated but considering the high risk of a third surgery, a palliative care support was collegially decided.

CONCLUSIONS

Left atrial dissection can occur after a redo surgery and supra-annular mitral valve implantation. Multi-modal imagery including transoesophageal echocardiography and cardiac CT-scan is helpful for the diagnosis.

A Comparison of the Catheter-Based Transapical and Surgical Treatment Modalities for Mitral Paravalvular Leak

Background: There is a lack of studies where the outcomes of mitral paravalvular leak treatment were compared between surgery and catheter-based closure. The aim of this study was to compare the outcomes of re-do surgery with transapical catheter-based paravalvular leak closure. Methods: This is a retrospective observational study at a single institution; 76 patients were included. According to the treatment, two groups were formed: the “Surgical” group (49 patients after re-do surgery) and the “Catheter” group (27 patients after transapical catheter–based treatment). Results: In-hospital myocardial infarction occurred in 9 (18%) cases in the “Surgical” group and none in the “Catheter” group, p = 0.018. Procedure-related life-threatening bleeding occurred in 9 (18%) patients in the “Surgical” group and none in the “Catheter” group, p = 0.018. Nine (18%) patients died in 30 days in the “Surgical” group, and none died in the “Catheter” group, p = 0.039. A mean follow-up was 3.3 years. No difference was found between the groups by the degree of residual paravalvular regurgitation either at discharge or at follow-up. During the follow-up, 19 (39%) patients died in the “Surgical” group and 2 (7%) among the “Catheter” patients. Conclusions: Transapical catheter-based closure of mitral paravalvular leak seems to be a safer treatment procedure than conventional re-do surgery, and the effectiveness of these procedures does not differ.

Percutaneous Paravalvular Leak Repair

Paravalvular leaks (PVLs) are challenging lesions that require a comprehensive understanding of surgical and transcatheter heart therapies, multimodality imaging, and transcatheter techniques. Approach to a transcatheter heart valve (THV) or surgical prosthesis for PVL differs in terms of options and varies according to the location (aortic or mitral). A suggested framework for transcatheter PVL repair is defect localization, access planning, defect crossing, sheath delivery. and occluder deployment. Careful planning facilitates success, but operators begin the case with a flexible mindset because many initial strategies may not succeed.

Transcatheter Closure of a Paravalvular Leak Guided by Transesophageal Echocardiography and Three-Dimensional Printing

Background

Closure of a percutaneous paravalvular leak (PVL) is a technically challenging procedure because of the specific anatomy postoperatively and the complex catheter techniques required. Transesophageal echocardiography (TEE) and three-dimensional (3D) printing might be helpful in identifying complex anatomical structures and the procedural design.

Objectives

The purpose of this study was to review our experiences with transcatheter closure of PVL guided by TEE and 3D (TEE&amp;3D) printing.

Methods

A total of 166 patients with PVL after surgical valve replacement underwent transcatheter closure, from January 2015 through December 2020. Among these patients, 68 had preoperative guidance from TEE&amp;3D printing. We reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up period was 36 (3–70) months.

Results

Acute procedural success was achieved in 154/166 (92.8%) patients; of these, 64/68 (94.1%) had TEE&amp;3D guidance and 90/98 (91.8%) had transthoracic echocardiography (TTE) guidance. No hospital deaths occurred. All patients having percutaneous procedures were given local anesthesia, while 13 patients having transapical procedures were given general anesthesia. Multiple approaches were used, including transfemoral, transapical, and transseptal via the arteriovenous loop. We also deployed multiple devices, including the Amplatzer Vascular Plug II (AVP II), the Amplatzer duct occluder II, the patent ductus arteriosus (PDA) occluder, and the Amplatzer muscular ventricular septal defect occluder. Those cases guided by TEE&amp;3D printing had shorter procedural times compared with those guided by TTE [(61.2 ± 23.4) vs. (105.7 ± 53.9) min, p &lt; 0.05]. The fluoroscopic time was also shorter for operations guided by TEE&amp;3D printing compared with those guided by TTE alone [(18.5 ± 11.4) vs. (27.3 ± 5.6) min, p &lt; 0.05]. The complications included recurrent hemolysis, residual regurgitation, acute renal insufficiency, and anemia. There was no significant difference in the incidence of complications between the 2 groups.

Conclusion

Transesophageal echocardiography and 3D printing show advantages compared with standalone TTE in guiding the transcatheter closure of PVL with shorter procedural and fluoroscopic times. This minimally invasive treatment could provide reliable outcomes in selected patients.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT02917980].

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.

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.

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.

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.

Paravalvular leak closure: Still a challenge with unpredictable results

INTRODUCTION

Paravalvular leak (PVL) is a common serious complication associated with prosthetic valve implantation.

OBJECTIVE

The aim of this study was to report our single-center experience in a retrospective review and to analyze possible predictors of success.

METHODS

We performed 33 percutaneous PVL closures in 26 patients (54% female, mean age 65±13 years). All mitral prostheses were studied previously with 3D transesophageal echocardiography (TEE), and aortic prostheses with 2D/3D TEE. 3D TEE and fluoroscopy were used for the assessment, planning, and guidance of the interventions. Twelve patients also underwent computed tomography angiography for better characterization of anatomic details.

RESULTS

Eighteen patients (69.2%) were admitted due to heart failure (New York Heart Association [NYHA] III or IV, seven (26.9%) because of heart failure and hemolysis, and one (3.8%) due to hemolysis only. Regarding the leaks, 46.2% were in aortic and 53.8% in mitral prostheses, 88.5% in mechanical and 7.7% in biological prostheses, and 3.8% in transcatheter aortic valve implants. All the aortic patients had severe aortic regurgitation. Furthermore, all mitral patients but one had moderate to severe or severe mitral regurgitation. Closure was successful in 17 patients (65.4%), partially successful in four (15.4%) and unsuccessful in five (19.2%). After the procedure, 69% were in NYHA I-II. Hemolysis worsened in three patients despite successful closure; all required further valvular surgery and two died. Regarding angiographic and echocardiographic procedural success, we analyzed age, gender, type of prosthesis (mechanical or biological), location (aortic or mitral), clinical data, maximum leak diameter, anatomic regurgitant orifice, leak location (anterior, posterior, inferior and lateral for mitral leaks and left, right and non-coronary sinus for aortic leaks), and number of devices (plugs) used for closure. No parameters presented a significant relationship with success excepting previous hemolysis. There was a relationship between clinical improvement and reduction of PVL (p=0.0001). In follow-up, cardiac-related events (new hospital admissions, cardiac valvular surgery, need for transfusion) were more frequent in patients with partially successful or unsuccessful closure (p=0.012). There was a relationship between cardiac-related events and death (p=0.029).

CONCLUSION

Percutaneous PVL closure has emerged as an alternative treatment for PVL. Predictors of procedural success are difficult to establish. Survival is related to reduction of regurgitation and improvement in NYHA functional class.

Percutaneous management of paravalvular leaks

Paravalvular leak (PVL) is a complication that occurs in 5-17% of patients after surgical prosthetic valve implantation. Whereas PVLs can be benign, some PVLs are associated with substantial morbidity and mortality. Percutaneous closure using occluders specifically designed to improve closure and reduce procedural complications has now become the first-line treatment for PVL. In this Review, we first detail the frequency and clinical consequences of PVL closure. The role of cardiac imaging in the assessment and management of PVL, including echocardiographic imaging and adjunctive techniques such as CT, is then discussed, together with important considerations for the percutaneous closure of PVL, such as access site and device selection. Finally, we summarize the clinical evidence for percutaneous closure of PVL, including large national registries from Ireland, Spain and the UK, as well as head-to-head data comparing this procedure with surgical closure.

Paravalvular Leaks-From Diagnosis to Management

PURPOSE OF REVIEW

As the number of surgical and transcatheter valve replacements continue to increase in the aging population, so does the incidence of paravalvular leak (PVL). Given its impact on morbidity and mortality, this article will focus on the epidemiology, clinical presentation, diagnostic assessment, and available treatments for PVL.

RECENT FINDINGS

Despite being performed on inoperable and typically higher risk patients, short-term complication rates of transcatheter PVL closure appear relatively low (< 10%). When indirectly compared with surgical PVL closure, long-term mortality, reoperation rates and degree of symptom improvement are similar. Nonetheless, current transcatheter closure devices are off-label and repurposed from other indications. Further development of percutaneous closure devices is an essential next step in order to improve and optimize outcomes. In patients with surgical and especially transcatheter-replaced heart valves, clinicians need to maintain vigilance for the presence of PVL, particularly in those with new-onset heart failure or hemolysis. Multimodality imaging is essential to detect and quantify PVL. Echocardiography (both transthoracic and transesophageal) is the backbone of diagnosis and quantification, and cardiac computed tomography and cardiac magnetic resonance imaging play an important role in defect characterization and in periprocedural planning. For those patients who are unable to undergo surgery, transcatheter PVL closure is an appropriate next step in management as it has similar outcomes to surgical intervention when performed in a center of expertise.

The Use of Intraoperative Three-Dimensional Echocardiography to Evaluate Origin of Bioprosthetic Aortic Valve Regurgitant Jets

Degradation of bioprosthetic aortic valves can eventually lead to both paravalvular and intravalvular regurgitation. However, differentiating between the two may be difficult in the case of multiple lesions in close proximity or highly eccentric jets. Whereas such exact distinction may be of little procedural significance in open cardiac surgery, it is of crucial importance when approaching such lesions in the catheterization laboratory or hybrid operating room. Interventions on one lesion often have a significant effect on the other. For example, guidewires may damage new bioprosthetic valve leaflets and dislodge vascular plugs. Even more concerning is the possibility of undergoing a lengthy and risky procedure on a lesion that does not truly exist. Fortunately, the use of three-dimensional Doppler echocardiography can expand our vision beyond the single imaging plane of a standard two-dimensional examination, allowing extensive manipulation of cutting planes and a wider field of view. Regurgitant jets can thus be tracked in a way that may be otherwise impossible, better quantifying their true origins. Here the authors present a unique case of misdiagnosis after surgical aortic valve degradation, where the use of intraoperative three-dimensional echocardiography significantly altered the preoperative plan and reduced operative time.

Transcatheter aortic valve implantation: a new standard of care

Aortic stenosis is the most common valvular lesion requiring intervention and with an ageing population, its burden is likely to increase. Increasing comorbidity and a desire for less invasive treatment strategies has facilitated the expansion of percutaneous aortic valve therapies. Robust clinical trial data are now available to support the role of transcatheter aortic valve implantation (TAVI) in patients of prohibitive, high and now intermediate surgical risk. The introduction of a Medicare Benefits Schedule reimbursement is likely to see TAVI use grow exponentially in Australia over the next 5 years. Clinical trials evaluating low risk patients may be the final frontier to see TAVI become the standard of care for most patients with severe aortic stenosis.

Autonomous Robotic Intracardiac Catheter Navigation Using Haptic Vision

While all minimally invasive procedures involve navigating from a small incision in the skin to the site of the intervention, it has not been previously demonstrated how this can be done autonomously. To show that autonomous navigation is possible, we investigated it in the hardest place to do it - inside the beating heart. We created a robotic catheter that can navigate through the blood-filled heart using wall-following algorithms inspired by positively thigmotactic animals. The catheter employs haptic vision, a hybrid sense using imaging for both touch-based surface identification and force sensing, to accomplish wall following inside the blood-filled heart. Through in vivo animal experiments, we demonstrate that the performance of an autonomously-controlled robotic catheter rivals that of an experienced clinician. Autonomous navigation is a fundamental capability on which more sophisticated levels of autonomy can be built, e.g., to perform a procedure. Similar to the role of automation in fighter aircraft, such capabilities can free the clinician to focus on the most critical aspects of the procedure while providing precise and repeatable tool motions independent of operator experience and fatigue.

Updated clinical indications for transcatheter aortic valve implantation in patients with severe aortic stenosis: expert opinion of the Italian Society of Cardiology and GISE

: The introduction of percutaneous treatment of severe aortic stenosis with transcatheter aortic valve implantation (TAVI) remains one of the greatest achievements of interventional cardiology. In fact, TAVI emerged as a better option than either medical therapy or balloon aortic valvuloplasty for patients who cannot undergo surgical aortic valve replacement (SAVR) or are at high surgical risk. Recently, increased operator experience and improved device systems have led to a worldwide trend toward the extension of TAVI to low-risk or intermediate-risk patients. In this expert opinion paper, we first discuss the basic pathophysiology of aortic stenosis in different settings then the key results of recent clinical investigations on TAVI in intermediate-risk aortic stenosis patients are summarized. Particular emphasis is placed on the results of the nordic aortic valve intervention, placement of aortic transcatheter valves (PARTNER) 2 and Surgical Replacement and Transcatheter Aortic Valve Implantation Randomized trials. The PARTNER 2 was the first large randomized trial that evaluated the outcome of TAVI in patients at intermediate risk. The PARTNER 2 data demonstrated that TAVI is a feasible and reasonable alternative to surgery in intermediate-risk patients (Society of Thoracic Surgeons 4-8%), especially if they are elderly or frail. There was a significant interaction between TAVI approach and mortality, with transfemoral TAVI showing superiority over SAVR. Moreover, we examine the complementary results of the recently concluded Surgical Replacement and Transcatheter Aortic Valve Implantation trial. This prospective randomized trial demonstrated that TAVI is comparable with surgery (primary end point 12.6% in the TAVI group vs. 14.0% in the SAVR group) in severe aortic stenosis patients deemed to be at intermediate risk. We review the most relevant clinical evidence deriving from nonrandomized studies and meta-analyses. Altogether, clinical outcome available data suggest that TAVI with a newer generation device might be the preferred treatment option in this patient subgroup. Finally, the differences between the latest European and American Guidelines on TAVI were reported and discussed. The conclusion of this expert opinion article is that TAVI, if feasible, is the treatment of choice in patients with prohibitive or high surgical risk and may lead to similar or lower early and midterm mortality rates compared with SAVR in intermediate-risk patients with severe aortic stenosis.

Paravalvular leak closure under intracardiac echocardiographic guidance

OBJECTIVES

The objective of this study was to determine the safety and efficacy of intracardiac echocardiography (ICE) to guide percutaneous paravalvular leak (PVL) closure.

BACKGROUND

PVL following surgical valve replacement occurs in 2%-15% of patients. Percutaneous treatment is an accepted management strategy in patients deemed to be too high risk for redo surgery. This is most commonly performed with transesophageal (TOE) guidance requiring general anesthesia that both potentially further increase the risk of intervention. ICE can be used to guide intervention, facilitating procedures to be performed under local anesthesia without esophageal intubation potentially making procedures shorter and safer and further enabling the treatment of patients that may have been turned down for intervention.

METHODS

All patients that underwent ICE-guided percutaneous transcatheter PVL closure between 2006 and 2016 at the John Radcliffe Hospital, Oxford, United Kingdom were retrospectively analyzed.

RESULTS

Twenty-one procedures were performed in 18 patients during the study period. Fourteen patients (77.8%) underwent successful ICE guided PVL closure. There were no ICE-related complications. Eleven patients (78.6%) reported symptomatic improvement of at least one New York Heart Association (NYHA) Class and the remaining 3 patients had no change. No patient demonstrated objective evidence of persistent hemolysis following successful closure. There was one death within 30 days of the procedure and 1 year survival was 71.4%.

CONCLUSIONS

Percutaneous paravalvular leak closure guided by ICE without the requirement of general anesthesia is feasible, safe, and associated with acceptable procedural success rates.

Cardioscopically Guided Beating Heart Surgery: Paravalvular Leak Repair

PURPOSE

There remains a paucity of direct visualization techniques for beating-heart intracardiac procedures. To address this need, we evaluated a novel cardioscope in the context of aortic paravalvular leaks (PVLs) localization and closure.

DESCRIPTION

A porcine aortic PVL model was created using a custom-made bioprosthetic valve, and PVL presence was verified by epicardial echocardiography. Transapical delivery of occlusion devices guided solely by cardioscopy was attempted 13 times in a total of three pigs. Device retrieval after release was attempted six times. Echocardiography, morphologic evaluation, and delivery time were used to assess results.

EVALUATION

Cardioscopic imaging enabled localization of PVLs via visualization of regurgitant jet flow in a paravalvular channel at the base of the prosthetic aortic valve. Occluders were successfully placed in 11 of 13 attempts (84.6%), taking on average 3:03 ± 1:34 min. Devices were cardioscopically removed successfully in three of six attempts (50%), taking 3:41 ± 1:46 min. No damage to the ventricle or annulus was observed at necropsy.

CONCLUSIONS

Cardioscopy can facilitate intracardiac interventions by providing direct visualization of anatomic structures inside the blood-filled, beating-heart model.

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.