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BACKGROUND The incidente of paravalvular leaks is variable
( from 2% to 7% ). It approaches 30% in those
operated because of paravalvular leak.
Surgical approach has been traditionally
considered the treatment of choice
In the past years an alternative therapeuticapproach has been sought
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Therapeutic Options
Medical treatment of hemolysis, CHF or both
Surgical repair of perivalvular leak #
Surgical replacement with a new valve #
Percutaneous repair of perivalvular leak ##
# Echevarria et al. Eur. Cardio Surg. 1991; 523-26.## -
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Kim et al. JACC Interv 2009; 2: 81-90
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TECHNIQUES
ortic Leak
iagnosis : Angiography and
Echocardiography
ascular access: Femoral or Brachial
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Aorta
Catheter
Guide Wire
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TECHNIQUES
Mitral Leak:
Diagnosis:
2D Echocardiography for diagnosis andlocation *
3D Echocardiography for size and shape **
Pre-procedural planing with rapidprototyping***
*Cortes et al. Am J Cardiol 2008; 101: 382-6 **Marx et al. Cardiol Clin 2007; 25:357-65
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Mitral leak
Right femoral vein and right/ left femoralartery approach
Transeptal puncture
Anterograde or retrograde leak approach
Amplatzer sheath to LV throught the leak
TEE procedural guidance
Amplatzer occluder positioning and release
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Mitral Leak
Transeptal puncture can be difficult andsometines requires SVC approach
Leak access: Antegrade or retrograde
Leak crossing: Terumo wire through IM(anterior), multipurpose (posterior) or RCA
( medial) catheters in antegrade approach
Terumo wire through multipurpose catheter inretrograde approach
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Result post procedure
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MITRAL PERIVALVULAR LEAKS
1. Use inflated Swan-Ganz catheter to undo LAloop and exchange high support wire
2. LA-LV-Ao with hydrophilic wire for wireexchange
3. Double transeptal for dual leak closure
4. Mid opening of the Amplatzer distal disk toavoid valve mechanism interference
Loosen up your imagination
(Special tricks)
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2D- 3D TEE Echocardioghraphy
Define leak anatomy
Guide leak passage of wire and device
Assess procedural result
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SURGICAL EXPERIENCE
136 Re-interventions (107 because ofparavalvular leak)
Operative mortality : 6.6%
Perioperative stroke : 5.1%
Freedom from repeated paravalvular leak :63%
K-M 10-year survival : 30%
Akins et al. J Heart V. Dis 2005; 14: 792-799
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PERCUTANEOUS RESULTS
Published reports : 10 papers , 52 patientsTechnical success : 44/52 ( 86% )
Clinical success : 28/52 ( 53%)
JACC 1992; 20:1371. CCI: 2005;65:69. JHVD 2007; 16:305. CCI 2000; 49:64. CCI2001; 54: 234. CCI 2007 ; 69: 708. CCI 2007; 70:815.
Kim et al..JACC, CCV Interventions 2009; 2: 81-90
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Personal experience
Procedures : 127
Mitral : 103
Aortic : 21
Mitro-aortic : 3
Devices : Duct occluder : 96. VPIII: 31
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AORTIC PARAVALVULAR LEAKS
ResultsProcedural success 16/17
Clinical improvement 14/17
Mortality ( > 3mo ) 1/17
Surgery ( > 3 mo ) 2/17
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MITRAL PARAVALVULAR LEAK
RESULTS N= 79Procedural success 60 /79 (76%)
Mortality( > 3 m ) 5/79 (6%)
Surgery ( > 3m ) 4/79 (5%)
Clinical improvement 55/79 ( 70%)
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AMPLATZER Vascular Plug III
Under review
Double-lobed, multi-
layer and oval-shaped
Extended rims for better
apposition in high flow
situations.
Faster occlusion time
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EXPERIENCE WITH THE NEW
DEVICE VP III
(January August 2009)Hospital Clinico San Carlos
Patients = 26, Procedures = 31 Devices =29)
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BASELINE
CHARACTERISTICSN= 26
Age 6311 yrs
Gender 14 male, 12 Female
Leak Location 22 Mitral, 3 Aortic, 1 Aorto mitral
Valve type 24 Mechanical, 3 Biological
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PROCEDURAL
CHARACTERISTICSN= 31
Vascular Access Femoral 29, Brachial 2
Loop ( A-V, A-A, V-V ) 23 (75%)
Delivery catheter AGA sheath ( 6-7 Fr.): 23Sheathless GC (6.5Fr): 3Destination GC ( 7Fr) : 2Heart Trail ( 6 Fr): GC
Device size 8/4 mm: 19;6/3 mm : 9;
10/5 mm :1;
12/5 : 1;
14/5: 1
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PROCEDURAL RES ULTSN= 31
Procedural success 28/31 ( 90 %)
Patient success 26/26 ( 100% )
Device success Complete closure : 17/29 ( 58% ),Partial closure ( 42%)
Complications : 2 pseudoaneurysms,
1 A-V fistula
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FUTURE DIRECTIONS
Better definition by different imagingmodalities
More experience with Rapid Prototyping
Improved lubrication of transporting sheathsto facilitate passage
Improve device design
Validate other options ( TRANSAPICALAPPROACH )
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CONCLUSIONS
The new VP III is anatomically and functionally moreadequate device to treat paravalvular leaks
The treatment of mitral paravalvular leaks is still aclallanging procedure
In most cases the retrograde access and an arterio-venous loop is an easier and faster way to repair mitral
paravalvular leaks
3D TEE is of great help to design and guide the procedure
Percutaneous repair of paravalvular leaks should be inmy opinin the first option of treatment