Transcatheter Closure of Mitral Paravalvular Leak via Multiple Approaches

Abstract

Objectives. The purpose of this study was to review the experiences with transcatheter closure of mitral PVL after surgical valve replacement. Background. Transcatheter closure of paravalvular leak (PVL) is an intricate alternative to surgical closure. But it represents one of the most intricate procedures in the field of structural heart interventions, especially for patients with mitral PVL. Methods. From January 2015 through January 2019, 35 patients with mitral PVL after valve replacement underwent transcatheter closure. We reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up was 26 (3–48) months. Results. Acute procedural success was achieved in 33/35 (94.3%) patients. Twenty-five patients had single mitral prosthetic valve replacements; 10 had combined aortic and mitral prosthetic valve replacements previously; 28 had mechanical valves; and 7 had bioprosthetic valves. All percutaneous procedures were performed with local anesthesia except for seven transapical cases with general anesthesia. Multiple approaches were used: transfemoral, transapical, and transseptal via an arteriovenous loop. Multiple devices were deployed. There were no hospital deaths. The procedural time was 67–300 (124 ± 62) minutes. Fluoroscopic time was 17–50 (23.6 ± 12.1) minutes. The hospital stay was 5–17 (8.3 ± 3.2) days. Complications included recurrent hemolysis, residual regurgitation, acute renal insufficiency, and anemia. Twenty-seven (77.1%) patients improved by ≥1 New York Heart Association functional class at the 1-year follow-up. Conclusions. Transcatheter mitral PVL closure requires complex catheter techniques. However, this minimally invasive treatment could provide reliable outcomes and shorter hospital stays in selected patients. This trial is registered with NCT02917980.

Transcatheter Mitral Valve-in-Valve Implantation Applying a Long Pre-Curved Sheath for Patients with Degenerated Bioprosthetic Mitral Valve

“…The measurement data guide procedural strategy and valve size selection. All patients' individual three dimensional (3D) printing models of the left heart were made based on X-ray computerized tomography (CT) data in order to help the operator to observe the anatomy accurately in the standard technique, as previously described [19] (Fig. 1).…”

Paravalvular Leaks: From Diagnosis to Management

“…Cardiac tomography-fluoroscopy fusion imaging was used in experienced teams to achieve more reproducible results, higher success, and better short and long terms outcomes. Also, the extension of indications and treatment with the confidence of complex, multiple PVLs (especially aortic PVLs) were allowed [20,21].…”

“…Approaches: For the mitral valve, the anterograde transeptal approach is the most used, however, an anterograde transaortic approach is more suitable for septal and posterior PVLs. The combination of both approaches forming an arteriovenous loop and transapical access are alternatives particularly for large or multiple PVLs necessitating the use of multiple devices [21]. The retrograde approach is not feasible in the case of mechanical aortic valve (Figure 2).…”

Mitral valve paravalvular leaks: Comprehensive review of literature

“…Clear evidence to best inform the optimal access route for mPVLs is scarce based on limited comparisons of different approaches, and currently, various centers adopt their own primary approaches. For instance, whilst the antegrade transseptal is widely used by Taramasso's center 12 and Eleid's group, 68 some opt for retrograde transfemoral 81 and transapical is reportedly preferred by others. 80,82 Antegrade transseptal with venous access is ideal for lesions located at the 12 o'clock position, as it allows easy access to the left atrium (LA).…”

“…83,84 Indeed, many have reported on the viability of this facile, safe and feasible 83 strategy-technical success rates from small sample sizes range between 89% and 100%. 12,77,81,85 In other instances of patients having combined mitral and AVRs, deployment of transapical repair is contingent on whether the aortic valve is bioprosthetic or mechanical.…”