Paravalvular regurgitation affects 5% to 17% of all surgically implanted prosthetic heart valves. Patients who have paravalvular regurgitation can be asymptomatic or present with hemolysis or heart failure, or both. Reoperation is associated with increased morbidity and is not always successful because of underlying tissue friability, inflammation, or calcification. Comprehensive echocardiographic imaging with transthoracic and real-time 3-dimensional transesophageal echocardiography is key for characterizing the defect location, size, and shape. For paramitral defects, an antegrade transseptal approach can usually be guided by biplane fluoroscopy, and real-time 3-dimensional transesophageal echocardiography can usually be performed successfully. Alternative approaches to paramitral defects include retrograde transaortic cannulation or transapical access and retrograde cannulation. For oblong or crescentic defects, the simultaneous or sequential deployment of 2 smaller devices, as opposed to 1 large device, results in a higher degree of procedural success and safety because the risk of impingement on the prosthetic leaflets is minimized. Most para-aortic defects can be approached in a retrograde manner and closed with a single device. With careful anatomical assessment, procedural planning, and procedural execution, successful closure rates of 90% or more should be attainable with a low risk of device impingement on the prosthetic valve or embolization.
Experience accumulated over 44 transfemoral aortic valve implantations led to significant decreases in procedural times, radiation, and contrast volumes. Our data show increasing proficiency with evidence of plateau after the first 30 cases. More studies are needed to confirm these findings.
A 59-year-old man underwent aortic root replacement with a mechanical aortic valve by means of a classic inclusion wrap Bentall procedure in 1989. He underwent repair of a leaking aortic graft pseudoaneurysm, along with triple-vessel coronary bypass, in 2006. Recent surveillance echocardiography discovered a large echolucent space posterolateral to the aortic root graft. Chest computed tomography (A) and transesophageal echocardiography (TEE) (B, Online Video 1) showed the recurrence of a large aortic pseudoaneurysm communicating with the aortic graft. The patient underwent percutaneous device closure of the pseudoaneurysm communication with a 10-mm Amplatzer septal occluder (AGA Medical Corporation, Minneapolis, Minnesota) (C, Online Video 2, which demonstrates cannulation of the aneurysm with a left coronary diagnostic catheter; D, Online Video 3, which shows the Amplatzer device in position). The device was in close proximity to the left main coronary artery; however, no ischemia occurred because grafts to the left coronary artery were patent. Successful placement was confirmed by 3-dimensional (3D) TEE (E, Online Video 4), with trivial residual flow seen on en-face color 3D TEE (F, Online Video 5). This case demonstrates the novel application of percutaneous device closure technology assisted by periprocedural 3D TEE imaging. (Please see Online Videos 6, 7, and 8 for additional real-time TEE imaging of the guiding catheter and occluder device deployment and positioning.)
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.