new percutaneous paravalvular leak...

Percutaneous paravalvular leak closure

eric.Eeckhout@chuv.ch

Lausanne - Switzerland

Potential Conflicts of interest

Speaker’s name: Eric Eeckhout

I have the following potential conflicts of interest to report:

Proctoring for St. Jude medical, Occlutech & Gore

Anatomical basics

Septal Anterior

Posterior Lateral

LAA

12

3

6

9

De Cicco G. Eur J Cardiothor Surg 2006:30:887-91

Percutaneous closure • No standarized technique (as many techniques

as operators) Off-label Dedicated material has emerged in the last years

• Pure percutaneous ante/retrograde

• Surgical transapical or hybrid

St. Jude medical

• St Jude Medical APV III series

• PDA & muscular VSD devices

Square Rectangular

T = twisted W = waist

Two shapes

Two connection types

Two radiopaque markers

Occlutech® PLD Occluder

• 50 year old Swiss male • Previous CABG (SVG RCA, LIMA LAD) • & 29mm ATS mitral valve 05.01.2015 (rheumatic fever) • Moderate aortic stenosis (1.7cm2) • Stage IV renal failure • Presence of 3 different mitral leaks, stage IV heart failure,

heamolysis • Heart team decision : attempt percutaneous closure at first

Clinical case

Baseline 3 D

Lateral Posterior

Retroaortic

Assessment of leak dimensions

Assessment of leak dimensions

Lausanne approach • Complete TOE to start with • General anesthesia, biplane room • Strive for optimal communication between echocardiographist and

interventionalist • Transseptal, crossing from LA to LV • AVP III (small slit-like defects, 3mm) • Muscular VSD (PDA) (larger leaks) • No experience at present with the Occlutech PLD occluder) • Strive for complete closure

Trans septal puncture

Agilis sheath

Agilis 8.5F medium curve

Closure of lateral leak

Straight 0.035 inch Terumo &

AR I 5F, Confida TAVI wire

9 12

6 3

Closure of lateral leak

TorqueVue I or II or Terumo Destination straight 90cm

Closure of lateral leak

AVP III 14-5mm

Destination 6F 90cm straight Destination 5F 90cm straight

Closure of posterior leak

12 9

6

3

9 12

6

3

Closure of posterior leak

Armed 7F Arrow sheath

for support

Closure of posterior leak

Closure of posterior leak

Closure of retroaortic leak

Closure of retroaortic leak

Impossible to cross with Destination 5F 90cm

12 9

6

3

Closure of retroaortic leak

Low pressure inflation with 6mm

peripheral balloon

Closure of retroaortic leak

Closure of retroaortic leak

Closure of retroaortic leak

Final result

Mean gradient 5mmHg

V wave reduction from 57 to 34mm Hg

Final result

• 63 year old Swiss-Asian male • Past history of rheumatic fever • Mechanical mitral valve prosthesis in 2001 for

mitral disease • Hemolysis required transfusion of regular basis • Stage I heart failure • Small septal paravalvular leak

Clinical case

TOE

12

3

6

9

Judged difficult upfront Double approach planned

Intervention

Intervention

Percutaneous echo guided transapical puncture

Intervention

Intervention

Intervention

• Honeycomb type leak

Teaching points failed case

• 71 year old Swiss female

• Past history of rheumatic fever

• Mechanical mitral valve prosthesis in 1996 for mitral valve disease

• Hemolysis required transfusion of regular basis

• Successfull closure by 2 serial APV III 14-5mm in 2011

• Doing fine until autumn 2016

Extra case

Before & after antegrade closure

2 serial APV III closure devices

Failure at 5 yrs follow-up

Potential complications

• Partial closure : Persistent heart failure Worsening or appearance of hemolytic anemia (Rigid devices>>> soft)

• Endocarditis, stroke

• Device embolisation

• Leaflet blockage

• Progression of the disease (recurrence)

• Erosion of biological valves

Conclusions • First line treatment if judged feasible

• Crucial role of imaging

• Understanding anatomy is understanding feasibility

• Learn to anticipate and treat complications (retrieval – blocked leaflets)

• Current devices offer acceptable results