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Transcript of Device Closure of Paravalvular Leak: Imaging in … Griffin_USA/Brian Griffin...Device Closure of...
Device Closure of Paravalvular Leak: Imaging in Patient Selection and Device Placement
Brian Griffin MD FACC
Section of Cardiovascular Imaging
Cleveland Clinic
Paravalvular Leak
• Usually at a valve replacement – mechanical or bioprosthetic, also at a ring in repair
• Mitral (7-17%) > aortic (2-10%)
• Most asymptomatic
• Major underlying cause – Technical failure – early – inadequate suturing
– Endocarditis – early or late, often in setting of preexisting infection
– Absence of adequate secure material to sew into
– Calcification of annulus – early or late
– Excess stress at sewing ring – anterolateral mitral annulus
– Percutaneous valve insertion – calcification, incorrect size
Mild Residual Paravalvular AR post TAVR
Excellent
symptomatic
result
2 years out
Paravalvular Leak: Major Sequelae • Often occult - exam, echocardiography
• 1-3% require reoperation or intervention
• Hemodynamic – severe regurgitation,
– low cardiac output,
– pulmonary hypertension with MR
• Hemolysis – due to red blood cell destruction – Jet hitting solid surface – rapid deceleration
– Anemia and frequent transfusion
– Jaundice, gallstones, high LDH, fragmentation of RBC
• Consequences of infection when present
• Usually progression – Eventual dehiscence
– Hemodynamic collapse
Paravalvular Leak: Evaluation • Usually CHF only (16%), Hemolysis only (14%) or
combination (70%)
• Symptomatic deterioration without obvious cause
• Unexpected anemia
• New pulmonary hypertension
• THINK paravalvular leak
• Blood – LDH, fragmentation, haptoglobin
• Echocardiography – If not obvious – always TEE
• Exclude infection – Blood cultures
Paravalvular Leak: Evaluation with
Echocardiography - TEE
• Determine severity of regurgitation – Quantify if possible
• Assess site of regurgitation – Often multiple leaks
– 3D imaging essential
• Exclude infection – Look for evidence of vegetation, abscess
• Determine whether prosthetic occluder/leaflets normal – Assess gradients
– Thrombus
• Is the valve dehiscing? – Valve rocking
– Extent of leak (s)
Paravalvular Leak: Decision to
Intervene
Surgical
• Infection present
• Dehiscence
• Leaflet problem
• Lower risk
• Percutaneous failure
Percutaneous
• Multiple prior surgery
• Mortality for reoperation
13% 1ST, 15% 2nd, 37% 3rd
• Localized site(s)
• High surgical risk
• Significant impairment
Amplatzer Devices used in Paravalvular
Leak repair
Percutaneous Closure of Paravalvular Leak
Sorajja et al Cath Cardiovasc Intervent 2007; 70:815-23
Occluder Deployed
Sorajja et al Cath Cardiovasc Intervent 2007; 70:815-23
Reduction in MR
N=16
14 mitral
81% success
No serious
sequelae
Sorajja et al Cath Cardiovasc Intervent 2007; 70:815-23
Recent Results of Paravalvular
Leak Closure
• N = 43 (57 procedures)
• 67% male
• Age 69 + 12 years
• 35% two prosthetic valves
• Attempted leaks 65% bioprosthetic, 35% mechanical
• Two procedures (n=10), Three procedures (n=2)
• Mitral (n=38, 26 one leak, 6 two leaks); aortic n=11
• One patient both aortic and mitral at 1 procedure
Ruiz et al JACC 2011; 58:2210-7
Recent Results of Paravalvular
Leak Closure: Procedural Success • Successful deployment 86% leaks and patients
• 12 failures
– 8 due to inability to cross defect
– 3 due to device interference with function of prosthesis
– 1 due to wire entrapment in defect at AVR
• Amplatzer duct occluder 69%, Amplatzer muscular VSD occluder 19%, Vascular Plug II 8%, Septal occluder in 4%
• Mitral 89% success, 4 % required additional procedure
• Aortic 73% success, 27% required second procedure
• 89% clinical success
• NYHA Class improved by 1(n=18), by 2 (n=8), by 3 (n=2), no improvement in 7 but 5 no longer needed transfusion
Ruiz et al JACC 2011; 58:2210-7
Recent Results of Paravalvular
Leak Closure: Complications • 6 complications
• 2 device embolization, both successfully closed, 1 device retrieved, the other remains in position
• 1 entrapped wire – surgical removal
• 1 iliac artery dissection, managed conservatively
• 2 cardiac perforations, pericardial effusion without tamponade, managed conservatively
• I death from PEA
• Prior reports suggest 33% have worse hemolysis, 10 % have new hemolysis – may require another procedure
• Transfusion need fell from 56% to 5% post procedure
• Survival was 92%, 89%, 87% at 6, 12, 18 months
Ruiz et al JACC 2011; 58:2210-7
78 yo Woman with Severe Hemolytic
Anemia:Guidance with RT3DTEE
• 15 years s/p St. Jude MVR
• Progressive hemolytic anemia over 2 years, now requiring 2 units/month
• Severe COPD (FEV1 0.7 liter)
• Hct 26, LDH 3000
• Not considered surgical candidate
Percutaneous Closure of Paravalvular MVR
5 mm hole
Percutaneous Closure of Paravalvular MVR
Direct visualization of paravalular leak
Percutaneous Closure of Paravalvular MVR
Direct visualization of both jets
Percutaneous Closure of Paravalvular MVR
Transseptal puncture
Percutaneous Closure of Paravalvular MVR
Passing retrograde wire
Percutaneous Closure of Paravalvular MVR
Retrograde wire with balloon occluder
Percutaneous Closure of Paravalvular MVR
Transseptal lasso catheter capturing
retrograde wire through leak
Percutaneous Closure of Paravalvular MVR
Transseptal lasso catheter capturing
retrograde wire through leak
Percutaneous Closure of Paravalvular MVR
Deployment of first occluder
Percutaneous Closure of Paravalvular MVR
Second retrograde wire in place
Percutaneous Closure of Paravalvular MVR
Second retrograde wire in place
Percutaneous Closure of Paravalvular MVR
Second deployment
Percutaneous Closure of Paravalvular MVR
Two closure plugs in place
Post Closure Images
Much less MR
78 yo Woman with Severe Hemolytic Anemia
Guidance with RT3DTEE
• Severity of regurgitation reduced to ~2+
• Hemolytic indices persisted but blood requirements reduced from 2 units/month to a few units/year
• Quality of life improved, within limits of severe COPD
75 year old man with 2 prior valve surgeries
Has severe shortness of breath
Mitral and aortic bioprosthesis with severe annular calcification and severe perivalvular MR
Now severe CHF
Has had endocarditis x 2 – staph epi and strep bovis
Culture negative
Moderate hemolysis LDH 800
Has colon cancer in right hemicolon
Now culture negative but increasing MR
Does not want another operation
TEE
TEE
3D TEE
75 year old man with Paravalvular Leak
• Given mobile structures and large area of
dehiscence, decision made to reoperate
• Operation performed on 2 successive days due to
bleeding
• AVR and MVR replaced – extensive calcification
and infection
• Excellent result – long hospitalization
• Colon cancer successfully removed – early stage
• No recurrence of paravalvular leak 3 months later
45 year old Man with Paravalvular
Leak and Hemolysis
• Mitral mechanical prosthesis
• Two prior surgeries
• Considered high risk operation
• Sizeable area of leakage, 2 closure devices
used
• Paravalvular occlusion attempted
• Improvement in transfusion requirements
and improved symptoms
Severe Paravalvular MR
3D Echo
Residual MR – improvement in hemolysis
45 year old Man with Paravalvular
Leak and Hemolysis
• He developed marked hemolysis after 1
year
• No CHF symptoms
• TEE performed
Hemolysis 1 year later
Recurrent hemolysis 1 year later
TEE
45 year old Man with Paravalvular
Leak and Hemolysis
• TEE confirms device movement and
rocking motion
• Underwent successful reoperation
• No recurrent leak