paravalvular leak - endovascular managementstatic.livemedia.gr/kebe/documents/al17324_us63... ·...
TRANSCRIPT
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PARAVALVULAR LEAK -ENDOVASCULAR MANAGEMENT
Petros S. Dardas, MD, FESCSt Lukes’ Hospital
Thessaloniki, GREECEIICE 2015
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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
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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
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Device selection
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Defects are typically crescenteric in nature
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Suitable device size?Amplatzer Vascular Plug III
••••
Oval-shapedThinner wiresMore wiresMultiple layers
smaller poresizeimprovedsurface contactfaster occlusion
Most of the leaksare not round!
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Mitral paravalvular leak
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Location of leaks-TEEMitral valve
76% ofparavalvularmitral valveleaks→
commissuralareas
Wunderlich NC et al. Cardiol Clin 2013 31(2): 237-70
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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
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Antegrade
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Huge left atrium
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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
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• 2014: increasing SOB + hemolysis
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Severe MR (grade IV)
2D TOE 3D colour
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3D posterior medial defect
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measurment
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measurment
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Stick posterior – need room to work
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Transeptal – superior and posterior
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transeptal
Transeptal sheath through Agilis catheter through
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AGILIS CATHETER
AGILIS directed posteriorly 5 Fr MP catheter – long TERUMO
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3D trying to cross
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TERUMO THROUGH
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TERUMO THROUGH
2D 3D
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MP through SUPERSTIFF wire
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SHUTTLE SHEATH through Amplatzersuperstiff wire
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AVIII DEPLOYMENT
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AVIII DEPLOYMENT
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AVIII DEPLOYMENT
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AVIII DEPLOYMENT
2D 3D
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AVIII DEPLOYMENT
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AV III final release
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2D post 1
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2D post 2
POST CLOSURE PRE CLOSURE
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AV III final result
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3D post
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2 days post closure
• Patient improved• NYHA I-II• Due for re TOE in 2 months
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2 MONTHS POST
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2 MONTHS POST
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Goal: Trivial Residual PVL
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Good occluder alignment
14x5mm AVPIII Okkluder
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Assessment before device release
• Proper device position?
• Valve leaflet obstruction byoccluder?
• Residual leak due to shape ofdefect?
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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
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2D TOE
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3D TOEIAS level (medial) – A3-P3
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1ST ATTEMPT AVP III 1ST ATTEMPT AVP III
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1ST ATTEMPT DEPLOYED 1ST ATTEMPT DEPLOYED
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1ST ATTEMPT UNSUCCESFULL
• PARA LEAK NOT SEALED
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2ND ATTEMPT AVP III DEPLOYED 2ND ATTEMPT AVP III DEPLOYED
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L DISK DEPLOYED L DISK DEPLOYED
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Normal prosthetic leaftlet motion can be impaired
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2ND ATTEMPT UNSUCCESFULL
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CENTRAL MR JET
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3d ATTEMPT SUCCESFULL 3d ATTEMPT SUCCESFULL
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AVP III SUCESFULLY DEPLOYED AVP III SUCCESFULLY DEPLOYED
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FINAL RESULT 30 mins POST
2D 3D
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3d case – RESIDUAL HOLE
• 70 female• AVR – MVR 25 years ago• Severe MV paravalvular leak – posterolateral• Hemolytic anemia LDH > 700• NYHA III
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2D COLOUR COLOUR MEASURMENT
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3D MEASUREMENT
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WIRE WIRE THROUGH
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2D POST 3D POST
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FINAL
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2D RESIDUAL HOLE 3D RESIDUAL HOLE
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3D MEASURMENT RESIDUAL HOLE
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PLAN
• REASSESS IN 3 MONTHS• RE CLOSURE IN 3 MONTHS AFTER FULL
ENDOTHELIALIZATION WITH 2ND DEVICE
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4TH case – DIFFICULT TO CROSS
• 68 male• AVR – MVR• Severe peravalvular leak
– 2 leaks anterolateral• NYHA III – IV• Severe PHT
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2D 2 JETS ANTEROLATERAL 2D 2 JETS
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2D COLOUR 2D COLOUR
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3D TOE
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2 TRANSEPTALS1ST TRANSEPTAL MID ANTERIOR-SUPERIOR
2ND TRANSEPTAL MOREPOSTERIOR
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2 TRANSEPTALS
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DIFFICULTY IN CROSSING TOOANTERIOR
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DIFFICULTY IN CROSSING TOOANTERIOR
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TOO ANTERIOR EXTREME ANTERIOR TILT
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FINAL CROSSING
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WIRE THROUGH
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SHUTTLE THROUGH
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AMPLATZER STIFF THROUGH
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DEPLOYMENT AV III ABNORMAL MOTION V DISC
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RE-DEPLOYMENT
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DIFFICULTY IN CROSSING TOOANTERIOR
STUCK VALVE DISK VALVE DISK RELEASED
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FINAL RESULT
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FINAL RESULT
2D SMALL RESIDUAL JET 3D
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• CLINICAL STATUS IMPROVED• DISCHARGED 3 DAYS LATER
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Aortic paravalvular leak
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•••••••
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
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High supportwire
Distal disk deployment
Sheath
Proximal disk deployment
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Device Release Final Result
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Complications
• AV leaflet movement is not compromised• coronary patency• anterior mitral valve leaflet should also be
evaluated
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Final Views
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Percutaneous PARAVALVULAR leakclosure
IS FEASIBLE
• Appropriate clinical indication (symptoms,hemolysis)• Proper anatomy• 2D – 3D TOE OBLIGATORY