PARAVALVULAR LEAK -ENDOVASCULAR MANAGEMENT

Petros S. Dardas, MD, FESCSt Lukes’ Hospital

Thessaloniki, GREECEIICE 2015

Symptoms of PVL

• 1-5% of patients with PVL are symptomatic• 93% of symptomatic patients present withCHF (69% ≥ NYHA III)

• 37% with hemolytic anemia• 7.5% with infective endocarditis

Prosthetic Valve RegurgitationRecommendations

Surgery is recommended for operable patients withmechanical heart valves with intractable hemolysisor HF due to severe prosthetic or paraprostheticregurgitationSurgery is reasonable for operable patients withsevere symptomatic or asymptomatic bioprostheticregurgitationPercutaneous repair of paravalvular regurgitation isreasonable in patients with prosthetic heart valvesand intractable hemolysis or NYHA class III/IV HFwho are at high risk for surgery and have anatomicfeatures suitable for catheter-based therapy whenperformed in centers with expertise in the procedure

COR

I

IIa

IIa

LOE

B

C

B

Device selection

Defects are typically crescenteric in nature

Suitable device size?Amplatzer Vascular Plug III

••••

Oval-shapedThinner wiresMore wiresMultiple layers

smaller poresizeimprovedsurface contactfaster occlusion

Most of the leaksare not round!

Mitral paravalvular leak

Location of leaks-TEEMitral valve

76% ofparavalvularmitral valveleaks→

commissuralareas

Wunderlich NC et al. Cardiol Clin 2013 31(2): 237-70

Access

• Transseptal– obtained under both fluoroscopic and transoesophageal

echocardiographic guidance to find an inferior and posterior septalposition

• Transfemoral– medial mitral paravalvular leaks

• Transapical– difficult-to-reach mitral leaks– patients with both mechanical aortic and mitral

valves

Antegrade

Huge left atrium

1st CASE

• 59 MALE• 1994: subaortic diaphragm resection + AV

clearance• 1995: SBE – AVR (biologic)• 1995: re SBE – AVR (metallic) + MVR (metallic)• 2010: MV paravalvular leak – re MVR with

bovine pericardial annulus + Aortic aneurysmrepair

• 2014: increasing SOB + hemolysis

Severe MR (grade IV)

2D TOE 3D colour

3D posterior medial defect

measurment

measurment

Stick posterior – need room to work

Transeptal – superior and posterior

transeptal

Transeptal sheath through Agilis catheter through

AGILIS CATHETER

AGILIS directed posteriorly 5 Fr MP catheter – long TERUMO

3D trying to cross

TERUMO THROUGH

TERUMO THROUGH

2D 3D

MP through SUPERSTIFF wire

SHUTTLE SHEATH through Amplatzersuperstiff wire

AVIII DEPLOYMENT

AVIII DEPLOYMENT

AVIII DEPLOYMENT

AVIII DEPLOYMENT

2D 3D

AVIII DEPLOYMENT

AV III final release

2D post 1

2D post 2

POST CLOSURE PRE CLOSURE

AV III final result

3D post

2 days post closure

• Patient improved• NYHA I-II• Due for re TOE in 2 months

2 MONTHS POST

2 MONTHS POST

Goal: Trivial Residual PVL

Good occluder alignment

14x5mm AVPIII Okkluder

Assessment before device release

• Proper device position?

• Valve leaflet obstruction byoccluder?

• Residual leak due to shape ofdefect?

2nd case – DIFFICULTIES INDEPLOYMENT

• 72 male• 2003 : MVR for severe degenerative MR• 2012 : redo for severe para-leak Hemolysis• 2014: severe anemia– Investigated fully– Severe hemolytic anemia- LDH 1500

• TTE + TOE

2D TOE

3D TOEIAS level (medial) – A3-P3

1ST ATTEMPT AVP III 1ST ATTEMPT AVP III

1ST ATTEMPT DEPLOYED 1ST ATTEMPT DEPLOYED

1ST ATTEMPT UNSUCCESFULL

• PARA LEAK NOT SEALED

2ND ATTEMPT AVP III DEPLOYED 2ND ATTEMPT AVP III DEPLOYED

L DISK DEPLOYED L DISK DEPLOYED

Normal prosthetic leaftlet motion can be impaired

2ND ATTEMPT UNSUCCESFULL

CENTRAL MR JET

3d ATTEMPT SUCCESFULL 3d ATTEMPT SUCCESFULL

AVP III SUCESFULLY DEPLOYED AVP III SUCCESFULLY DEPLOYED

FINAL RESULT 30 mins POST

2D 3D

3d case – RESIDUAL HOLE

• 70 female• AVR – MVR 25 years ago• Severe MV paravalvular leak – posterolateral• Hemolytic anemia LDH > 700• NYHA III

2D COLOUR COLOUR MEASURMENT

3D MEASUREMENT

WIRE WIRE THROUGH

2D POST 3D POST

FINAL

2D RESIDUAL HOLE 3D RESIDUAL HOLE

3D MEASURMENT RESIDUAL HOLE

PLAN

• REASSESS IN 3 MONTHS• RE CLOSURE IN 3 MONTHS AFTER FULL

ENDOTHELIALIZATION WITH 2ND DEVICE

4TH case – DIFFICULT TO CROSS

• 68 male• AVR – MVR• Severe peravalvular leak

– 2 leaks anterolateral• NYHA III – IV• Severe PHT

2D 2 JETS ANTEROLATERAL 2D 2 JETS

2D COLOUR 2D COLOUR

3D TOE

2 TRANSEPTALS1ST TRANSEPTAL MID ANTERIOR-SUPERIOR

2ND TRANSEPTAL MOREPOSTERIOR

2 TRANSEPTALS

DIFFICULTY IN CROSSING TOOANTERIOR

DIFFICULTY IN CROSSING TOOANTERIOR

TOO ANTERIOR EXTREME ANTERIOR TILT

FINAL CROSSING

WIRE THROUGH

SHUTTLE THROUGH

AMPLATZER STIFF THROUGH

DEPLOYMENT AV III ABNORMAL MOTION V DISC

RE-DEPLOYMENT

DIFFICULTY IN CROSSING TOOANTERIOR

STUCK VALVE DISK VALVE DISK RELEASED

FINAL RESULT

FINAL RESULT

2D SMALL RESIDUAL JET 3D

• CLINICAL STATUS IMPROVED• DISCHARGED 3 DAYS LATER

Aortic paravalvular leak

•••••••

Femoral artery access.Fluoro guidance ±TEEMultiporpouse or RCAStraight tip Terumo wireHigh support wire.Long 6-7 Fr. sheathDevice ( AV P III )deployment with

(± TEEangiographicguidance )

Usual caseAortic leak

High supportwire

Distal disk deployment

Sheath

Proximal disk deployment

Device Release Final Result

Complications

• AV leaflet movement is not compromised• coronary patency• anterior mitral valve leaflet should also be

evaluated

Final Views

Percutaneous PARAVALVULAR leakclosure

IS FEASIBLE

• Appropriate clinical indication (symptoms,hemolysis)• Proper anatomy• 2D – 3D TOE OBLIGATORY