device closure of paravalvular leak: imaging in … griffin_usa/brian griffin...device closure of...
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Device Closure of Paravalvular Leak: Imaging in Patient Selection and Device Placement
Brian Griffin MD FACC
Section of Cardiovascular Imaging
Cleveland Clinic
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Paravalvular Leak
• Usually at a valve replacement – mechanical or bioprosthetic, also at a ring in repair
• Mitral (7-17%) > aortic (2-10%)
• Most asymptomatic
• Major underlying cause – Technical failure – early – inadequate suturing
– Endocarditis – early or late, often in setting of preexisting infection
– Absence of adequate secure material to sew into
– Calcification of annulus – early or late
– Excess stress at sewing ring – anterolateral mitral annulus
– Percutaneous valve insertion – calcification, incorrect size
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Mild Residual Paravalvular AR post TAVR
Excellent
symptomatic
result
2 years out
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Paravalvular Leak: Major Sequelae • Often occult - exam, echocardiography
• 1-3% require reoperation or intervention
• Hemodynamic – severe regurgitation,
– low cardiac output,
– pulmonary hypertension with MR
• Hemolysis – due to red blood cell destruction – Jet hitting solid surface – rapid deceleration
– Anemia and frequent transfusion
– Jaundice, gallstones, high LDH, fragmentation of RBC
• Consequences of infection when present
• Usually progression – Eventual dehiscence
– Hemodynamic collapse
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Paravalvular Leak: Evaluation • Usually CHF only (16%), Hemolysis only (14%) or
combination (70%)
• Symptomatic deterioration without obvious cause
• Unexpected anemia
• New pulmonary hypertension
• THINK paravalvular leak
• Blood – LDH, fragmentation, haptoglobin
• Echocardiography – If not obvious – always TEE
• Exclude infection – Blood cultures
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Paravalvular Leak: Evaluation with
Echocardiography - TEE
• Determine severity of regurgitation – Quantify if possible
• Assess site of regurgitation – Often multiple leaks
– 3D imaging essential
• Exclude infection – Look for evidence of vegetation, abscess
• Determine whether prosthetic occluder/leaflets normal – Assess gradients
– Thrombus
• Is the valve dehiscing? – Valve rocking
– Extent of leak (s)
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Paravalvular Leak: Decision to
Intervene
Surgical
• Infection present
• Dehiscence
• Leaflet problem
• Lower risk
• Percutaneous failure
Percutaneous
• Multiple prior surgery
• Mortality for reoperation
13% 1ST, 15% 2nd, 37% 3rd
• Localized site(s)
• High surgical risk
• Significant impairment
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Amplatzer Devices used in Paravalvular
Leak repair
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Percutaneous Closure of Paravalvular Leak
Sorajja et al Cath Cardiovasc Intervent 2007; 70:815-23
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Occluder Deployed
Sorajja et al Cath Cardiovasc Intervent 2007; 70:815-23
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Reduction in MR
N=16
14 mitral
81% success
No serious
sequelae
Sorajja et al Cath Cardiovasc Intervent 2007; 70:815-23
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Recent Results of Paravalvular
Leak Closure
• N = 43 (57 procedures)
• 67% male
• Age 69 + 12 years
• 35% two prosthetic valves
• Attempted leaks 65% bioprosthetic, 35% mechanical
• Two procedures (n=10), Three procedures (n=2)
• Mitral (n=38, 26 one leak, 6 two leaks); aortic n=11
• One patient both aortic and mitral at 1 procedure
Ruiz et al JACC 2011; 58:2210-7
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Recent Results of Paravalvular
Leak Closure: Procedural Success • Successful deployment 86% leaks and patients
• 12 failures
– 8 due to inability to cross defect
– 3 due to device interference with function of prosthesis
– 1 due to wire entrapment in defect at AVR
• Amplatzer duct occluder 69%, Amplatzer muscular VSD occluder 19%, Vascular Plug II 8%, Septal occluder in 4%
• Mitral 89% success, 4 % required additional procedure
• Aortic 73% success, 27% required second procedure
• 89% clinical success
• NYHA Class improved by 1(n=18), by 2 (n=8), by 3 (n=2), no improvement in 7 but 5 no longer needed transfusion
Ruiz et al JACC 2011; 58:2210-7
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Recent Results of Paravalvular
Leak Closure: Complications • 6 complications
• 2 device embolization, both successfully closed, 1 device retrieved, the other remains in position
• 1 entrapped wire – surgical removal
• 1 iliac artery dissection, managed conservatively
• 2 cardiac perforations, pericardial effusion without tamponade, managed conservatively
• I death from PEA
• Prior reports suggest 33% have worse hemolysis, 10 % have new hemolysis – may require another procedure
• Transfusion need fell from 56% to 5% post procedure
• Survival was 92%, 89%, 87% at 6, 12, 18 months
Ruiz et al JACC 2011; 58:2210-7
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78 yo Woman with Severe Hemolytic
Anemia:Guidance with RT3DTEE
• 15 years s/p St. Jude MVR
• Progressive hemolytic anemia over 2 years, now requiring 2 units/month
• Severe COPD (FEV1 0.7 liter)
• Hct 26, LDH 3000
• Not considered surgical candidate
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Percutaneous Closure of Paravalvular MVR
5 mm hole
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Percutaneous Closure of Paravalvular MVR
Direct visualization of paravalular leak
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Percutaneous Closure of Paravalvular MVR
Direct visualization of both jets
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Percutaneous Closure of Paravalvular MVR
Transseptal puncture
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Percutaneous Closure of Paravalvular MVR
Passing retrograde wire
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Percutaneous Closure of Paravalvular MVR
Retrograde wire with balloon occluder
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Percutaneous Closure of Paravalvular MVR
Transseptal lasso catheter capturing
retrograde wire through leak
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Percutaneous Closure of Paravalvular MVR
Transseptal lasso catheter capturing
retrograde wire through leak
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Percutaneous Closure of Paravalvular MVR
Deployment of first occluder
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Percutaneous Closure of Paravalvular MVR
Second retrograde wire in place
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Percutaneous Closure of Paravalvular MVR
Second retrograde wire in place
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Percutaneous Closure of Paravalvular MVR
Second deployment
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Percutaneous Closure of Paravalvular MVR
Two closure plugs in place
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Post Closure Images
Much less MR
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78 yo Woman with Severe Hemolytic Anemia
Guidance with RT3DTEE
• Severity of regurgitation reduced to ~2+
• Hemolytic indices persisted but blood requirements reduced from 2 units/month to a few units/year
• Quality of life improved, within limits of severe COPD
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75 year old man with 2 prior valve surgeries
Has severe shortness of breath
Mitral and aortic bioprosthesis with severe annular calcification and severe perivalvular MR
Now severe CHF
Has had endocarditis x 2 – staph epi and strep bovis
Culture negative
Moderate hemolysis LDH 800
Has colon cancer in right hemicolon
Now culture negative but increasing MR
Does not want another operation
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TEE
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TEE
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3D TEE
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75 year old man with Paravalvular Leak
• Given mobile structures and large area of
dehiscence, decision made to reoperate
• Operation performed on 2 successive days due to
bleeding
• AVR and MVR replaced – extensive calcification
and infection
• Excellent result – long hospitalization
• Colon cancer successfully removed – early stage
• No recurrence of paravalvular leak 3 months later
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45 year old Man with Paravalvular
Leak and Hemolysis
• Mitral mechanical prosthesis
• Two prior surgeries
• Considered high risk operation
• Sizeable area of leakage, 2 closure devices
used
• Paravalvular occlusion attempted
• Improvement in transfusion requirements
and improved symptoms
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Severe Paravalvular MR
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3D Echo
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Residual MR – improvement in hemolysis
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45 year old Man with Paravalvular
Leak and Hemolysis
• He developed marked hemolysis after 1
year
• No CHF symptoms
• TEE performed
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Hemolysis 1 year later
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Recurrent hemolysis 1 year later
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TEE
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45 year old Man with Paravalvular
Leak and Hemolysis
• TEE confirms device movement and
rocking motion
• Underwent successful reoperation
• No recurrent leak