New Percutaneous paravalvular leak...
Transcript of New Percutaneous paravalvular leak...
![Page 1: New Percutaneous paravalvular leak closuretsc2019.tamduchearthospital.com/pdf/p1/134-pvltamduc.pdf · 2019. 10. 14. · •& 29mm ATS mitral valve 05.01.2015 (rheumatic fever) •Moderate](https://reader033.fdocuments.in/reader033/viewer/2022060706/6071cac66938363354282e1f/html5/thumbnails/1.jpg)
Percutaneous paravalvular leak closure
Lausanne - Switzerland
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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
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Anatomical basics
Septal Anterior
Posterior Lateral
LAA
12
3
6
9
De Cicco G. Eur J Cardiothor Surg 2006:30:887-91
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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
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St. Jude medical
• St Jude Medical APV III series
• PDA & muscular VSD devices
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Square Rectangular
T = twisted W = waist
Two shapes
Two connection types
Two radiopaque markers
Occlutech® PLD Occluder
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• 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
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Baseline 3 D
Lateral Posterior
Retroaortic
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Assessment of leak dimensions
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Assessment of leak dimensions
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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
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Trans septal puncture
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Agilis sheath
Agilis 8.5F medium curve
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Closure of lateral leak
Straight 0.035 inch Terumo &
AR I 5F, Confida TAVI wire
9 12
6 3
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Closure of lateral leak
TorqueVue I or II or Terumo Destination straight 90cm
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Closure of lateral leak
AVP III 14-5mm
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Destination 6F 90cm straight Destination 5F 90cm straight
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Closure of posterior leak
12 9
6
3
9 12
6
3
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Closure of posterior leak
Armed 7F Arrow sheath
for support
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Closure of posterior leak
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Closure of posterior leak
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Closure of retroaortic leak
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Closure of retroaortic leak
Impossible to cross with Destination 5F 90cm
12 9
6
3
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Closure of retroaortic leak
Low pressure inflation with 6mm
peripheral balloon
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Closure of retroaortic leak
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Closure of retroaortic leak
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Closure of retroaortic leak
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Final result
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Mean gradient 5mmHg
V wave reduction from 57 to 34mm Hg
Final result
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• 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
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TOE
12
3
6
9
Judged difficult upfront Double approach planned
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Intervention
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Intervention
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Percutaneous echo guided transapical puncture
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Intervention
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Intervention
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Intervention
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• Honeycomb type leak
Teaching points failed case
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• 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
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Before & after antegrade closure
2 serial APV III closure devices
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Failure at 5 yrs follow-up
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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
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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
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