Transcatheter closure of a mechanical perivalvular leak using real‐time three‐dimensional transesophageal echocardiography guidance

A 47‐year‐old female with symptomatic mitral stenosis from a prior undersized mitral annuloplasty ring underwent mitral valve replacement with a mechanical valve. Later, she developed heart failure from a severe paravalvular leak (PVL). Because of the excessive mortality risks from a possible third open heart procedure, the patient was instead referred for transcatheter PVL closure. Standard fluoroscopy, invasive hemodynamics, and two‐dimensional (2D) and three‐dimensional (3D) transesophageal echocardiography (TEE) imaging were performed during device placement with excellent image quality. The case highlights the unique benefit of 3D TEE imaging for preprocedure sizing, guidance of device deployment intraprocedure, and confirmation of PVL closure. © 2011 Wiley‐Liss, Inc.     

Mitral paravalvular leak closure by antegrade percutaneous approach using amplatzer PFO closure device

Percutaneous closure of paravalvular leaks is becoming a more widely practiced technique. We describe the technique we used to deploy an Amplatzer PFO closure device to treat a prosthetic mitral paravalvular leak. The procedure was performed under real time 3D trans‐oesophageal echo and fluoroscopic guidance requiring a trans‐septal puncture and utilising an 035″ Safari wire which was developed for TAVR implantation. An excellent result was achieved acutely and at 4 month follow‐up. © 2016 Wiley Periodicals, Inc.     

Two‐step approach of percutaneous closure of a paravalvular leak and atrial septal defect after mitral valve reoperation

Severe paravalvular leakage following mitral valve replacement, a rare but potentially serious complication, may result in heart failure and significant hemolysis. Reoperation is considered standard of care. However, in selected patients, re‐do sternotomy carries excessively high surgical risk. Percutaneous closure of paravalvular leaks has become a viable option for these patients. We present a case of a highly symptomatic 42‐year‐old male who underwent successful percutaneous closure of two paravalvular leaks and a post‐operative atrial septal defect after re‐do mitral valve replacement surgery. As access to the left atrium was expected to be difficult following percutaneous atrial septal defect closure, a two‐step approach of paravalvular leak closure followed by atrial septal defect closure was chosen. Difficulties of atrial septal defect closure following closure of a paravalvular leak next to the inter‐atrial septum will be discussed. © 2011 Wiley‐Liss, Inc.     

Percutaneous closure of tricuspid paravalvular leak

While transcatheter closure of mitral and aortic paravalvular leaks has been well‐described, there are no prior reports of such procedures for prosthetic tricuspid valves. We describe our experience with percutaneous closure of a tricuspid paravalvular leak in a 34‐year‐old patient with a history of tricuspid atresia. He had previously undergone repair with placement of a right atrium‐to‐right ventricle conduit and most recently, placement of a bio‐prosthetic tricuspid valve. He subsequently developed significant tricuspid paravalvular leak with symptoms of severe right heart failure. His clinical status was improved following successful transcatheter closure of the defect. © 2013 Wiley Periodicals, Inc.     

Transcatheter trans‐apical closure of paravalvular mitral and aortic leaks using a new device: First in man experience

This report describes the first use of a new paravalvular leak (PVL) device designed specifically to close paravalvular mitral and paravalvular aortic leaks. The first patient had severe paravalvular mitral leak that was closed using the transapical route with a rectangular designed PVL device that has an oval waist for self‐centering and the second patient had moderate paravalvular aortic leak that was closed with a square designed device that has a round waist for self‐centering. Both patients had complete closure. © 2013 Wiley Periodicals, Inc.     

Computed Tomography–Derived 3D Modeling to Guide Sizing and Planning of Transcatheter Mitral Valve Interventions

A plethora of catheter-based strategies have been developed to treat mitral valve disease. Evolving 3-dimensional (3D) multidetector computed tomography (MDCT) technology can accurately reconstruct the mitral valve by means of 3-dimensional computational modeling (3DCM) to allow virtual implantation of catheter-based devices. 3D printing complements computational modeling and offers implanting physician teams the opportunity to evaluate devices in life-size replicas of patient-specific cardiac anatomy. MDCT-derived 3D computational and 3D-printed modeling provides unprecedented insights to facilitate hands-on procedural planning, device training, and retrospective procedural evaluation. This overview summarizes current concepts and provides insight into the application of MDCT-derived 3DCM and 3D printing for the planning of transcatheter mitral valve replacement and closure of paravalvular leaks. Additionally, future directions in the development of 3DCM will be discussed.     

Percutaneous Closure of Mitral Paravalvular Leak via Retrograde Approach with Use of the Amplatzer Duct Occluder II and without a Wire Loop

The gold-standard treatment for prosthetic-valve paravalvular leakage is surgery to repair or replace the valve; however, the morbidity and mortality rates cannot be ignored, and some patients are poor surgical candidates. The percutaneous closure of such defects is possible, and different devices are being used for this purpose. In almost all instances, a femorofemoral or femorojugular wire loop is constructed to deliver the closure device. Herein, we present the case of a 61-year-old man in whom a mitral paravalvular leak was successfully closed with use of the Amplatzer® Duct Occluder II, via retrograde approach under 3-dimensional transesophageal echocardiographic guidance, without the use of a wire loop. To the best of our knowledge, this is the 1st report of retrograde device deployment without the construction of an arteriovenous wire loop, and the 1st case in which the Amplatzer Duct Occluder II was used for the percutaneous closure of a mitral paravalvular leak.Key words: Echocardiography, transesophageal; heart catheterization; heart valve prosthesis implantation/adverse effects/instrumentation; mitral valve insufficiency; postoperative hemorrhage/etiology; prosthesis design; prosthesis failure; treatment outcomeParavalvular leakage after mechanical valve implantation is a relatively rare sequela. It occurs in approximately 5% of cases, with an incidence as high as 0.6% per patient-year.¹ Paravalvular leaks develop as a result of suture rupture, and they vary in size. Small leaks can be asymptomatic or cause hemolysis, whereas larger leaks can cause serious hemodynamic changes and heart failure. The surgical treatment of paravalvular leaks is associated with morbidity and death.² Over the past few years, percutaneous closure of these defects has been reported, with the use of different devices and technical approaches.³Herein, we report the percutaneous closure of a mitral paravalvular leak, under the guidance of 3-dimensional (3D) transesophageal echocardiography (TEE), via a retrograde approach and without the need to fashion an arteriovenous wire loop.     

Three‐Dimensional Echocardiography‐Guided Repair of Residual Shunt after Percutaneous Atrial Septal Defect Closure

A 28‐year‐old woman was referred to closure of a residual shunt produced through a percutaneous device previously implanted in the atrial septum. The imaging protocol to guide the procedure included 2D TEE and real time 3D (RT3D) transesophageal echocardiography (TEE) imaging. RT3D TEE facilitated the evaluation of the defect morphology, and the relationship with the previous device, allowing a proper understanding of the mechanism responsible for the residual shunt. It was also a useful tool for guiding device deployment, providing clear intraprocedural information about catheter position and the spatial relationship with the previous device. In conclusion, RT3D TEE and 2D TEE are complementary techniques for the evaluation and guidance of transcatheter closure of complex atrial septal defects. (Echocardiography 2011;28:E64‐E67)     

Retrograde Transcatheter Closure of Mitral Paravalvular Leak through a Mechanical Aortic Valve Prosthesis: 2 Successful Cases

The presence of a mechanical aortic valve prosthesis has been considered a contraindication to retrograde percutaneous closure of mitral paravalvular leaks, because passing a catheter through the mechanical aortic valve can affect the function of a mechanical valve and thereby lead to severe hemodynamic deterioration. We report what we believe are the first 2 cases of retrograde transcatheter closure of mitral paravalvular leaks through a mechanical aortic valve prosthesis without transseptal or transapical puncture. Our experience shows that retrograde transcatheter closure of mitral paravalvular leaks in this manner can be an optional approach for transcatheter closure of such leaks, especially when a transapical or transseptal puncture approach is not feasible. This technique might also be applied to other transcatheter procedures in which there is a need to pass a catheter through a mechanical aortic valve prosthesis.     

Transapical repair of mitral valve paravalvular leakage using 3‐D transesophageal guidance

We report a case where transapical access with real time 3D transesophageal echocardiographic guidance is used for repair of a mitral valve paravalvular leakage. The transapical approach is a new, elegant, and relative safe alternative for repair of a paravalvular defect in high‐risk patients. The use of real time 3DTEE for guiding the procedure provides the operator fast and complete information about the leakage, and allowing online monitoring of the procedure. © 2010 Wiley‐Liss, Inc.     

Percutaneous Retrograde Closure of Mitral Paravalvular Leak in Patients With Mechanical Aortic Valve Prostheses

Mechanical aortic valve prostheses are considered a limiting factor when contemplating percutaneous closure of mitral paravalvular leaks using a retrograde approach. However, transfemoral artery access and a retrograde approach have advantages over a trans-septal anterograde approach when the paravalvular defect is large with a significant gradient or when the defect is medial to the mitral valve. We describe a novel technique of mitral paravalvular leak closure in the presence of a mechanical aortic valve prosthesis, which we performed successfully in 3 patients. The technique uses a retrograde approach and arteriovenous wire loop.     

Live/Real Time Three-Dimensional Transesophageal Echocardiographic Evaluation of Mitral and Aortic Valve Prosthetic Paravalvular Regurgitation

Thirteen patients already scheduled for surgery for repair of prosthetic paravalvular regurgitation underwent intraoperative real time two-dimensional transesophageal echocardiography (2D TEE) and live/real time three-dimensional transesophageal echocardiography (3D TEE). In all patients, 3D TEE was able to provide more information regarding the location and size of the paravalvular defect as compared to 2D TEE. 3D TEE resulted in a more accurate localization of the defect and an estimation of the size of the defect that correlated much more closely with surgical findings when compared with 2D TEE. Our preliminary results demonstrate the superiority of 3D TEE over 2D TEE in the evaluation of paravalvular prosthetic regurgitation. 3D TEE not only provides an accurate assessment of the exact site of the leakage, but also gives a more accurate estimate of its size. This information could be valuable to surgeons who may encounter difficulty when localizing and estimating the size of paraprosthetic leaks while the heart is devoid of blood during surgery.     

Three‐Dimensional Transesophageal Echocardiography Assessment of a Successful Transcatheter Mitral Valve in Valve Implantation for Degenerated Bioprosthesis

Reoperation for degenerated mitral bioprosthesis is considered a high risk procedure. Transcatheter mitral valve in valve implantation has emerged as an off‐label alternative for patients contra‐indicated to surgery. We report a 46‐year‐old man, with a 29 mm mitral bioprosthesis since 2002, who was admitted for acute heart failure because of a severe intra‐prosthetic regurgitation. His recent medical history revealed a fast growing cavum carcinoma. In view of generally poor prognosis, the heart team decided to perform a transcatheter mitral valve in valve implantation by transapical approach. Live three‐dimensional TEE was used during the implantation for sizing, device positioning, and hemodynamic assessment.     

Usefulness of transesophageal echocardiography in percutaneous transcatheter repairs of paravalvular mitral regurgitation

This study was conducted to assess the usefulness of transesophageal echocardiography (TEE) as a guide in the percutaneous transcatheter occlusion of paravalvular defects and in subsequent follow-up. In 27 consecutive patients with mitral paravalvular leaks with significant regurgitation considered to be poor surgical candidates who were treated with percutaneous closure of the defects, TEE was performed before and during the procedure. If the device was successfully positioned, a reevaluation was made 1 month later. Events occurring during the procedure and 1-month follow-up were recorded. The device was correctly positioned in 17 of the patients (63%). TEE enabled the detection of complications (intraprosthetic insufficiencies due to passing the guide through the prosthesis, blockade of the prosthesis, etc.). It also confirmed the correct canalization of the leak with the catheter and the position of the device. In 8 patients (47% of patients with successful implantation), the degree of regurgitation was substantially reduced after 1 month. In conclusion, TEE is a fundamental technique when considering the percutaneous treatment of paravalvular leaks in patients with high surgical risk. It provides essential information on the characteristics of the dehiscence during implantation and follow-up.     

Utility of Three-Dimensional Echocardiography in Percutaneous Closure of Paravalvular Leak

The images and videos presented in this case report demonstrate the utility of live three-dimensional (3D) transoesophageal echocardiography (TEE) in guiding the percutaneous closure of paravalvular leak (PVL). This method provides high-quality real time assistance for transseptal puncture and deployment of the closure device through the PVL.     

Percutaneous Retrograde Transfemoral Closure of Mitral Paravalvular Leak in 3 Patients without Construction of an Arteriovenous Wire Loop

Percutaneous closure of paravalvular leaks has emerged as an alternative to repeated surgeries. Different percutaneous techniques and various devices have been used, off-label, for paravalvular leak closure. For mitral leaks, antegrade transseptal, retrograde transfemoral, and retrograde transapical techniques have been developed. In the antegrade transseptal approach, an arteriovenous guidewire loop is often created to advance the delivery sheath. In retrograde transfemoral closure, the wire in the left atrium is usually snared after transseptal puncture, to pull it from the femoral vein. The delivery sheath and closure device will subsequently be deployed from the left atrium. Each of these procedures takes time, is costly, and increases the risk of complications.We present the cases of 3 patients in whom we closed mitral paravalvular leaks by means of a retrograde transfemoral approach, with use of an Amplatzer™ Duct Occluder II device and without the construction of an arteriovenous wire loop. We think that this approach can be very useful in a specific group of patients—reducing costs, fluoroscopy times, and complications related to transseptal puncture and construction of an arteriovenous wire loop. In our institution, this reported technique is routinely used for mitral paravalvular leak closure.     

The challenge of integrated echocardiographic approach in percutaneous closure of paravalvular leak

Paravalvular leak after prosthetic mitral valve surgery may lead to symptomatic mitral regurgitation and hemolytic anemia requiring reoperation. Percutaneous closure of paravalvular leaks is a relatively recent technique still considered a challenging procedure burdened by possible complications, to be offered only to poor redo surgical candidate patients. Multimodality imaging is advocated to plan and guide the procedure, to minimize the risk of complications. We report on a case of dehisced prosthetic mitral valve in which transthoracic real time three-dimensional echocardiography was used to locate the dehiscence area and characterize mitral paraprosthesis leak, whereas intracardiac echocardiography was used to guide and monitor the percutaneous closure procedure.     

Endocarditis of amplatzer® occluder devices after percutaneous closure of a mitral paravalvular leak

Symptomatic paravalvular leaks (PVL) are a relatively uncommon, but potentially significant postoperative complication of valve replacement surgery. Percutaneous repair of PVLs has become an increasingly utilized approach in patients whose comorbidities obviate surgical repair. We present an interesting case of a gentleman who underwent successful repair of a mitral PVL with Amplatzer devices following initial aortic and mitral valve replacements for bacterial endocarditis. He later developed fungal endocarditis that ultimately required re‐operation to remove the devices and replace his mitral and aortic valves. This complication of closure devices, although reportedly rare, should be considered when contemplating a percutaneous approach. © 2012 Wiley Periodicals, Inc.     

Multiplane two-dimensional versus real time three-dimensional transesophageal echocardiography in ischemic mitral regurgitation

Objectives: Intraoperative three‐dimensional (3D) transesophageal echocardiography (TEE) has been suggested to be a valuable technique for the evaluation of the mechanisms of ischemic mitral regurgitation (IMR). Studies comparing multiplane two‐dimensional (2D) with 3D TEE reconstruction of the mitral valve using the new mitral valve quantification (MVQ) software are lacking. We undertook a prospective comparison between multiplane 2D and 3D TEE for the assessment of IMR. Methods: We evaluated echocardiographically 45 patients with IMR who underwent mitral valve surgery in our institution. 2D and 3D TEE examinations followed by a 3D offline assessment of the mitral valve apparatus were performed in all patients. Offline analysis of mitral valve apparatus was conducted with QLAB–MVQ. Results: 3D TEE image acquisitions were performed in a short period of time and were feasible in all patients. Real time 3D TEE imaging was superior to 2D in identifying specific mitral scallops (A1, A3, P1, P3) and commissures. When compared with 2D TEE, 3D offline reconstruction of the mitral valve allows an accurate quantification of the shape and diameters of the mitral annulus. Both approaches provide almost similar values for the tenting area and the coaptation depth. The 3D approach gave the advantage of direct calculation of the leaflets angles, tenting volume, and surface of the leaflets. The interpapillary muscles distance at the level of the papillary muscle head was greater in 2D than in 3D. Conclusions: 3D TEE imaging provides valuable and complementary information to multiplane 2D TEE for the assessment of patients with IMR. (Echocardiography 2011;28:1125‐1132)     

Successful repositioning of apically tethered transcatheter mitral valve replacement in the off‐bypass,beating heart

A 73‐year‐old man with severe, symptomatic secondary mitral regurgitation (MR) underwent successful transcatheter mitral valve replacement using the Tendyne? mitral valve system. The device was deployed from the left ventricular (LV) apex and secured in position by a tether attached to an epicardial pad. Three days postoperatively, the patient developed hemolytic anemia and a paravalvular leak (PVL) associated with indentation of the LV apex. Adjustment of the tether tension and placement of an epicardial disc under the pad resulted in reduction in the PVL, and resolution of the hemolytic anemia.