mitral pvl closure when and how?...pld device with a pair of softer avp3 devices (better chance of...

Mitral PVL Closure – When and How?

Carmen Maria Moldovan

Konstantinos Aznaouridis

Hippokrateion Hospital

European Heart Journal (2017) 00, 1–53

Transcatheter Paravalvular Leak Closure, Springer 2017

Transcatheter PVL Closure – Safe, Feasible and Efficient treatment

Conflicting data on whether mild-to-moderate PVL affects prognosis and should be addressed

in an asymptomatic patient

PVL closure – When don’t close!Aortic/ Mitral valve replacement- Trans or Para?

• Large defect > 25% with rocking

unstable valve

• Prosthetic dysfunction

• Local infection

• Recent surgery < 6 weeks

1st Department of Cardiology, University of Athens

• Imaging (unfeasible without 2D/3D TOE)

• Steep Learning curve (>50 cases)

• Patients selection (High Risk)

• Head to head comparison of surgical and

catheter based interventions


Transcatheter Mitral PVL Closure

Most echo dependent cardiac structural interventions

Technically demanding Procedure

• TTE, TOE, 3-D, MDCT

• Severity, location, shape, size, number

• Plan the approach, choice the device

• Guide safe & optimal device placement


Transcatheter Mitral PVL Closure

Most echo dependent cardiac structural interventions

What we need from imaging?

3D-TOE and MDCT help in PVL orifice localization and measurementwas described using the “clock-face” system

Wunderlich et al, J Am Coll Cardiol Img 2018;11:872–901)

It is necessary to refer PVL in relation to

anatomic reference points (TOE)Anatomical Description model for location of a PVL (MDCT)

A comprehensive description of PVL anatomy is of paramount importance3D Color Doppler TEE for Mitral PVL Quantification ARO versus ERO

Measurement of the PVL’s “narrow neck” if present

Franco et al, J Am Soc Echocardiogr 2014;27:1153-63

Anatomic orifice area (ARO):

Extraction of the 2D plane that includes

the anatomic orifice of the leak

Effective orifice area (ERO):

The frame in which the origin of the

regurgitant jet is best visualized is

selected.

Then the multiplanar reconstruction tool

allows the selection of the 2D plane that

best shows the regurgitant orifice

Technical aspects of image acquisitionDevice Selection - Multiplug Devices AVPIII vs Single Device PLD


Importance of channel measurement in choosing the right PVL closure device Different theory for PLD devices(undersizing) vs. AVP devices (oversizing)


Closure Devices



• 73-year-old male patient who presented with progressive severe dyspnea (NYHA III).

• AVR (1995) and MVR (2010) for rheumatic calcified valve disease.

• Labs consistent with mild hemolysis (hemoglobin level, 9.9 g/dL; reticulocyte count, 1,8%; and

lactate dehydrogenase level 600 U/L).

• Heart failure symptoms BUT no severe hemolysis .

• A TOE showed two localized mitral paravalvular leak that caused moderate to severe regurgitation.

One defect was anterolateral at 10-11 o'clock position and a smaller at 7-8 o'clock position. After

the patient was informed of the treatment options in detail, he agreed to undergo percutaneous

closure (antegrade, transseptal approach) of the defect.

Anterolat PVL

Posterolat PVL

Multiple mitral paravalvular leaks

Gafoor et al, Interventional Cardiology Review, 2015;10(2):112–7

The authors recommend closing the major leak

only at first, as if there is significant

infection/hemolysis, the offending device can be

identified.

The authors place multiple devices or close

multiple leaks if there is uncertain follow-up or

with two equally sized large leaks.


Wire in LA

Anterolateral mitral PVL closure – Transseptal approach

tenting

Wire through to LA but new transvalvular MR jet



lateral

medial

Wire through leak

Anterolat PVL


Amplatz

Super stiff

wire

5Fr multipurpose

catheter via a

steerable sheath


Occlutech PLD

12x5mm

markers PLD device

mild residual MR

PLD device

Delivery

sheath


Reduction of CD mapped flow

Comparison of VC CSA by RT 3D TEE with CD

Reduction in transprosthetic gradient

Normalization of flow pattern in PV

Echo contrast (SEC) in usually dilated LA

Lower LA pressure

Assessment of TPVLC acute procedural effect

markers PLD device

2 months follow upColour flow jets persisted and unfortunately haemolysis worsened


• Labs consistent with worse

hemolysis (hemoglobin level,

8.5 g/dL; reticulocyte count,

2,5%; and lactate

dehydrogenase level 1400

U/L).

• Continues to need transfusions

PLD device Residual MR jet

2nd PVL jet

• Small high-velocity mitral

PVL jets can cause

haemolysis out of proportion

to the echocardiographic

findings

G. Smolka et al., Arch Med Sci 2017; 13, 3: 575–584

• Significant hemolysis (a rate of 1.6%) is more frequent in:

• calcified defect

• mitral location of PVL

• TPVLC more effectively reduces hemolytic anemia if >90% reduction of PVL VC CSA is achieved.

• Incomplete TPVLC even if reducing HF symptoms may result in exacerbation of hemolytic anemia.

• In majority of multiple plugs strategy is necessary for complete sealing. In some cases when needed replacing the suspect

PLD device with a pair of softer AVP3 devices (better chance of fixing the haemolysis).

• The deployment of multiple “smaller devices” rather than one or two “larger devices” has a better sealing within the PVL

and less interference with the prosthesis discs.

What to do?Persistent hemolysis after percutaneous PVL closure:

1. Repeat PVL closure by removing the old closure device and implanting new ones:

• Risk of tissue tear, defect enlargement, device embolization or stroke (cerebral protection device?).

• Great risks, device not interfering with valve closure, the device should be left in situ.

2. Repeat mitral valve surgery

• The most complete solution, but at highest risk.

• Failed mitral surgery, anticipated 3rd thoracotomy and pulmonary hypertension!! We would not choose this option.

3. A third option is to try to locate, size and fix the remaining jet using a different device.

• The Ampatzer Vascular Plug 4 (AVP4) is ideally suited to this type of mechanical gluing.

• The aim would need to be to obliterate any remaining paravalvular colour flow (technically challenging).

4. The fourth and final option is to "wait and hope".

• As devices endothelialise, so the shearing forces on the red cells will diminish and, in time, there is a chance that the need for transfusion will

reduce and finally disappear (force-feed the patient vitamin C to strengthen the red cell membranes).

G. Smolka et al., Arch Med Sci 2017; 13, 3: 575–584

Millán X et al., Can J Cardiol. 2015 Mar;31(3):260-9

Take home messages from our case

• The interventional strategy, and in particular the choice of the type and size of the closure device, is of

utmost importance to assure immediate and long-term success.

• Whatever device is chosen, operators should strive towards an almost complete and immediate PVL

closure as assessed by postoperative TOE.

• Incomplete closure, in particular after implantation of a « more rigid » Occlutech PLD device may worsen

pre-existing or induce new-onset haemolysis with potential fatal outcomes.

• The main challenge is to assess whether the residual post-procedural hemolysis is related to a malposition of

the vascular plug and residual jet, or to the non endothelialization of the device (no visible residual jet).

Millán X et al., Can J Cardiol. 2015 Mar;31(3):260-9

Transapical Mitral PVL closure

• 67-year-old female patient who presented with progressive severe dyspnea (NYHA III).

• AVR and MVR (2004) for rheumatic valve disease.

• Labs consistent with severe hemolysis (hemoglobin level, 8,5 g/dL; reticulocyte count, 2,5%; and

lactate dehydrogenase level 1200 U/L).

• Heart failure symptoms AND severe hemolysis .

• A TOE showed one localized mitral paravalvular leak that caused moderate to severe regurgitation.

The defect was posteromedial at 4-5 o'clock position. She agreed to undergo percutaneous closure

(transapical approach) of the defect.

Postero medial

PVL

medial PVL

post. PVL


Transvalvular MR jet


Acoustic

shadowing

PVL jet

Wire in LA

Rectangular PLD device

12x5 mm


Device

deployment

5 Fr

multipurpose

catheter

Amplatz

Super Stiff

wire


Device in

place

Thank you

mitral pvl closure when and how?...pld device with a pair of softer avp3 devices (better chance of...

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