New Percutaneous paravalvular leak...
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Transcript of New Percutaneous paravalvular leak...
Percutaneous paravalvular leak closure
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
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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
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6
3
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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
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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
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3
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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
