Percutaneous versus surgical closure of paravalvular leaks in prosthetic valves: A cross-sectional comparison of clinical outcomes

Background and Aims

Paravalvular leak (PVL) is a serious complication of prosthetic valve replacement. Both surgical and percutaneous closure techniques are used for PVL closure, but optimal strategies and comparative outcomes are uncertain. This study aimed to compare the efficacy and safety of percutaneous versus surgical PVL closure by analyzing changes in leak severity, functional status, echocardiographic parameters, and clinical outcomes.

Methods

A total of 72 patients were included in this retrospective cross-sectional single-center study comparing percutaneous (n = 25) and surgical (n = 47) PVL closure from 2015 to 2022. Demographics, medical history, echocardiograms, laboratory data, complications, and mortality data were extracted from the records. Changes in leak severity, NYHA class, echocardiographic parameters, and clinical outcomes were compared between the percutaneous and surgical groups.

Results

Both percutaneous and surgical PVL closure significantly reduced leak severity and improved NYHA class (both p < 0.01), with no difference between the quantity of changes in each group. The 30-day mortality was 4% after percutaneous and 6.4% after surgical closure (p = 0.65). At 90 days, mortality was 24% percutaneous versus 17% surgical (p = 0.48). The length of stay in the hospital and post-procedural decrease in hemoglobin were considerably lower in the percutaneous group. The rate of complication rates was similar between the groups. Echocardiographic changes were also comparable.

Conclusion

Percutaneous and surgical PVL closure had similar efficacy in reducing leaks and improving symptoms, with no significant difference in early outcomes. Both options should be considered viable for PVL repair after heart team evaluation.

Transcatheter mitral paravalvular closure: a single centre experience with techniques and outcomes

BACKGROUND

In patients with symptomatic mitral PVL, successful transcatheter reduction of the PVL to less than mild is associated with significant improvement in short- and midterm survival.

OBJECTIVES

In this study, we present our single-centre, same operators' experience on percutaneous paravalvular leak closure with techniques and outcomes.

METHODS

In this retrospective observational designed study, we retrieved hospital records of patients with a surgical history of mechanical or biological prosthetic valve replacement and who subsequently underwent transcatheter mitral paravalvular leak closure (TMPLC). All procedures were performed by the same operators.

RESULTS

A total of 45 patients with 58 PVDs underwent TMPLC using 60 devices. All patients had moderate or severe mitral paravalvular regurgitation associated with symptomatic HF (15.6%), clinically significant haemolytic anaemia (57.8%) or both (26.7%). The technical success rate was 91.4%, with 53 defects successfully occluded. The clinical success rate was 75.6%. Among the clinical success parameters, the preprocedural median ejection fraction increased from 45% (35-55) to 50% (40-55) (p = .04). Mitral gradients decreased from max/mean 18/8 mmHg to max/mean 16/7 mmHg; p = .02). Haemoglobin levels increased from 9.9 (8.5-11.1) to 11.1 (3-13); p = .003. LDH levels decreased from 875 (556-1125) to 435 (314-579); p: <.001. All-cause 30-day and in-hospital mortality rates were the same at 8.9%.

CONCLUSION

This single-centre study with a limited number of patients confirmed that TMPLC is a safe and effective procedure to improve symptoms and severity of PVL.

Intractable Heart Failure From a Severe Mitral Paravalvular Leak in Surgically Created Bipartite Left Atrium

We describe a 38-year-old Middle Eastern woman with a long history of multiple cardiac surgical procedures for mitral valve disease who presented with intractable heart failure from severe mitral paravalvular regurgitation requiring multiple medical admissions since 2019. She was deemed a very high surgical risk and was treated successfully with a percutaneous technique. (Level of Difficulty: Advanced.)

Percutaneous Paravalvular Leak Repair

Paravalvular leaks (PVLs) are challenging lesions that require a comprehensive understanding of surgical and transcatheter heart therapies, multimodality imaging, and transcatheter techniques. Approach to a transcatheter heart valve (THV) or surgical prosthesis for PVL differs in terms of options and varies according to the location (aortic or mitral). A suggested framework for transcatheter PVL repair is defect localization, access planning, defect crossing, sheath delivery. and occluder deployment. Careful planning facilitates success, but operators begin the case with a flexible mindset because many initial strategies may not succeed.

Transcatheter Closure of a Paravalvular Leak Guided by Transesophageal Echocardiography and Three-Dimensional Printing

Background

Closure of a percutaneous paravalvular leak (PVL) is a technically challenging procedure because of the specific anatomy postoperatively and the complex catheter techniques required. Transesophageal echocardiography (TEE) and three-dimensional (3D) printing might be helpful in identifying complex anatomical structures and the procedural design.

Objectives

The purpose of this study was to review our experiences with transcatheter closure of PVL guided by TEE and 3D (TEE&amp;3D) printing.

Methods

A total of 166 patients with PVL after surgical valve replacement underwent transcatheter closure, from January 2015 through December 2020. Among these patients, 68 had preoperative guidance from TEE&amp;3D printing. We reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up period was 36 (3–70) months.

Results

Acute procedural success was achieved in 154/166 (92.8%) patients; of these, 64/68 (94.1%) had TEE&amp;3D guidance and 90/98 (91.8%) had transthoracic echocardiography (TTE) guidance. No hospital deaths occurred. All patients having percutaneous procedures were given local anesthesia, while 13 patients having transapical procedures were given general anesthesia. Multiple approaches were used, including transfemoral, transapical, and transseptal via the arteriovenous loop. We also deployed multiple devices, including the Amplatzer Vascular Plug II (AVP II), the Amplatzer duct occluder II, the patent ductus arteriosus (PDA) occluder, and the Amplatzer muscular ventricular septal defect occluder. Those cases guided by TEE&amp;3D printing had shorter procedural times compared with those guided by TTE [(61.2 ± 23.4) vs. (105.7 ± 53.9) min, p &lt; 0.05]. The fluoroscopic time was also shorter for operations guided by TEE&amp;3D printing compared with those guided by TTE alone [(18.5 ± 11.4) vs. (27.3 ± 5.6) min, p &lt; 0.05]. The complications included recurrent hemolysis, residual regurgitation, acute renal insufficiency, and anemia. There was no significant difference in the incidence of complications between the 2 groups.

Conclusion

Transesophageal echocardiography and 3D printing show advantages compared with standalone TTE in guiding the transcatheter closure of PVL with shorter procedural and fluoroscopic times. This minimally invasive treatment could provide reliable outcomes in selected patients.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT02917980].

Mitral valve paravalvular leaks: Comprehensive review of literature

BACKGROUND

Mitral paravalvular leaks (mPVL) are a recognized complication for patients with mitral valve prostheses. Although clinically insignificant for many patients, it may pose life-threatening haemolysis and regurgitation-induced heart failure, and so clinicians should have a high index of suspicion in the presence of new symptoms.

AIMS

This review discusses the pathogenesis, clinical features, diagnosis, imaging and treatment of mPVLs.

METHODS

A comprehensive literature search was performed using PubMed, EMBASE, Cochrane database, Google Scholar and Ovid. Search terms used included "mitral valve paravalvular leak," "transthoracic echocardiography," "2D transoesophageal echocardiography," "3D transoesophageal echocardiography," "cardiac computed tomography," (CT) "cardiac magnetic resonance imaging," "intracardiac echocardiography," "cinefluoroscopy," "fluoroscopy," and "percutaneous closure."

RESULTS

All patients with mPVLs should undergo regular full evaluation, including patient history, physical examination, laboratory work-up, imaging, and referral, if necessary. Echocardiography is fundamental to the diagnosis, and is augmented with cardiac magnetic resonance imaging, cardiac computerized tomography and fluoroscopy for further characterization and procedural planning amongst the structural heart team.

CONCLUSION

The prevalence of mPVL is expected to increase proportionally to the growing number of surgical and transcatheter valve replacements conducted in the ageing population. Multimodal imaging is instrumental in guiding diagnostic and therapeutic strategies when managing mPVLs. Advances in imaging and capabilities of transcather devices will prompt growing uptake of percutaneous treatment over conventional, higher-risk surgery for mPVL management.

Percutaneous management of paravalvular leaks

Paravalvular leak (PVL) is a challenging complication of valve replacement surgery that can cause heart failure and haemolysis. Surgical repair is the traditional treatment for severe, symptomatic PVL, but many patients with PVL fall into high-risk categories for redo surgery. Percutaneous techniques for closure of PVL have been increasingly refined over the last decade with availability of approved purpose-specific devices for closure. Percutaneous closure requires a heart team approach, with attention paid to appropriate preprocedural and periprocedural imaging to ensure a successful closure with minimal residual leak or complication. There are limited studies addressing the selection of a percutaneous approach to PVL. No randomised trials comparing surgical and percutaneous repair have been conducted. Large national registries from the UK and Ireland and from Spain have demonstrated that high rates of technical success can be achieved, with mortality comparable with surgical repair. Six retrospective studies comparing surgical and percutaneous approaches have been published. These broadly show comparable technical success between the interventions, with reduced short-term mortality among patients treated percutaneously. Long-term outcomes were similar between both treatment options. Percutaneous repair is an attractive treatment option in many patients due to its reduced invasiveness and quicker recovery period. However, more prospective studies are needed to validate its place in the armamentarium of the heart team.

Left Ventricular Apex: A "Minimally Invasive Motorway" for Safe Cardiovascular Procedures

Since the advent of TAVR (transcatheter aortic valve replacement), the transapical surgical approach has been affirmed as a safe and effective alternative access for patients with unsuitable peripheral arteries. With the improvement of devices for transfemoral approach and the development of other alternative accesses, the number of transapical procedures has decreased significantly worldwide. The left ventricular apex, however, has proved to be a safe and valid alternative access for various other structural heart procedures such as mitral valve repair, mitral valve-in-valve or valve-in-ring replacement, transcatheter mitral valve replacement (TMVR), transcatheter mitral paravalvular leak repair, and thoracic aorta endovascular repair (TEVAR). We review the literature and our experience of various hybrid transcatheter structural heart procedures using the transapical surgical approach and discuss pros and cons.

Percutaneous devices for the treatment of complex native valve mitral leaflet and aortomitral continuity defects: Review and case series

Percutaneous closure of paravalvar leaks (PVLs) was once only performed in extreme or non-surgical risk cases not suitable for redo-surgery with tissue or mechanical valves. This technique is now the treatment of choice with long term outcomes that are better than redo operations.¹²³ As interventionalists become more familiar with using PVL devices, more off label device use has been reported in non-surgical cases involving complex native mitral valve regurgitation (NVMR). In this review, we appraise the literature regarding percutaneous treatment of paravalvar leaks and more recently esoteric off label use. We also describe two recent challenging cases where percutaneous devices were used to treat severe leaks that developed as a sequela of previous infective endocarditis. We also provide specific recommendations regarding periprocedural strategy and focus on the importance of device choice to provide an optimal outcome.

Transcatheter Closure of Mitral Paravalvular Leak via Multiple Approaches

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.

Structural and Functional Characteristics of Mitral Paravalvular Leakage Identified by Multimodal Imaging and Their Implication on Clinical Presentation

OBJECTIVE

Clinical presentation of patients with mitral paravalvular leakage (PVL) varies from asymptomatic to heart failure related with hemolytic anemia or pulmonary hypertension. We aimed to investigate the structural and functional characteristics of mitral PVL by multimodal imaging and their association with the severity of hemolysis and hemodynamic significance.

METHODS

A total of 74 patients with mitral PVL who underwent both cardiac computed tomography (CT) and echocardiography from March 2010 to December 2017 was investigated. Location and size of PVL, degree of left atrial (LA) calcification as measured by CT, and hemodynamic variables as measured by echocardiography were comprehensively analyzed. To investigate the degree of hemolysis and pulmonary hypertension, level of lactate dehydrogenase (LDH) and Doppler estimated systolic pulmonary artery pressure (SPAP) were used respectively.

RESULTS

Level of LDH was not related to PVL perimeter and was variable, especially in patients with a small PVL. However, it was positively correlated with mean mitral regurgitation velocity. Additionally, SPAP was significantly correlated with PVL perimeter and LA calcium score. In multivariable analysis, mean mitral regurgitation velocity was significantly correlated with levels of LDH (β = 0.345; p = 0.016), and PVL perimeter and LA calcium score were independently associated with SPAP (β = 0.249; p = 0.036 and β = 0.467; p < 0.001, respectively).

CONCLUSIONS

Characteristics of mitral PVL and adjacent structures are associated with the severity of hemolysis and pulmonary hypertension. Evaluating the structural and functional characteristics of mitral PVL by complementary multimodal imaging would be important for understanding the clinical presentation and deciding optimal treatments for individual patients.

Elective Percutaneous Paravalvular Leak Closure Under Conscious Sedation: Procedural Techniques and Clinical Outcomes

BACKGROUND

Paravalvular leaks (PVLs) are a well-recognized complication of prosthetic valves that are detected up to 18% of all implanted surgical valves. Perioperative morbidity is thought to be lower in percutaneous compared to surgical PVL repair. However, a direct comparison of PVL closure techniques has never been performed. Our study is the first to demonstrate that elective PVL closure with monitored anesthesia care can be achieved with high success and low complications rates resulting in short hospital stays.

METHODS

This is a retrospective cohort of patients admitted electively for catheter-based treatment of symptomatic prosthetic paravalvular regurgitation from Jan 2013 to April 2018. Both mitral and aortic PVLs were included. Patients' demographics, risk factors, procedural outcomes, In-hospital and thirty-day mortality were all reported. We followed the Valve Academic Research Consortium (VARC) criteria to define device and procedural technical success. In-hospital and 30- day outcomes were assessed by retrospective chart review.

RESULTS

A total of 54 PVLs in thirty-seven patients were repaired (65% aortic & 35% mitral). The mean-age in the mitral cohort was lower than the aortic cohort (61 vs 72years, P<0.0001) but the two groups shared similar clinical risk factors (P>0.05). Average hospital stay was 1-2days (<1.5days overall cohort) which was significantly lower in the aortic compared to the mitral cohort (P=0.009). All procedures were guided by TEE under conscious sedation with monitored anesthesia care. Procedural technical success defined as any significant residual shunt was 81% in the overall cohort and 88% in the aortic group. No procedural deaths were reported. Short-term mortality during the first 30days was 5.4% (two patients).

CONCLUSION

Elective catheter-based repair of symptomatic prosthetic paravalvular regurgitation appears to be safe and effective. The use of conscious sedation with monitored anesthesia care resulted in short hospital stay.

Long-term outcomes after reoperation for mitral paravalvular leaks: a single-centre experience

OBJECTIVES

We aimed to analyse the pathology of paravalvular leak (PVL), and determine the long-term outcomes of redo mitral valve replacement and risk factors of all-cause mortality.

METHODS

Seventy-nine patients (mean age 70 ± 9 years; 54 female, 68%) who underwent redo mitral valve replacement for mitral PVL between January 2000 and May 2019 were retrospectively reviewed. Indications for PVL intervention were haemolytic anaemia (57/79, 72%), New York Heart Association class III/IV congestive heart failure (56/79, 71%) and prosthetic valve endocarditis with PVL (2/79, 3%).

RESULTS

PVL most commonly occurred at lateral sectors (42/79, 55%). Early mortality occurred in 2 patients (3%) due to low cardiac output syndrome. Two patients (3%) had residual PVL at discharge. Sixteen patients (23%) developed late PVL (mean follow-up, 3.4 ± 2.9 years), among whom 11 (69%) developed PVL at same area as that preoperatively. Additionally, 9 patients (56%) developed PVL at lateral sectors in late follow-up. At 1, 5 and 10 years, the survival rate was 93%, 72% and 45%; rate of freedom from cardiac death was 96%, 92% and 78%; and rate of freedom from PVL recurrence was 94%, 82% and 54%, respectively. Chronic kidney disease was the only risk factor in the multivariate analysis for mortality [P = 0.013; hazard ratio 4.0 (1.4-11.0)].

CONCLUSIONS

Surgery for mitral PVL confers reasonable early and long-term outcomes. Greater attention to the anterolateral annulus may help prevent PVL.

Novel Use of Echo Fusion and Cardiac Computed Tomographic Imaging Guidance for Percutaneous Paravalvular Leak Closure

•

Echo fusion overlays echocardiographic cardiac structures over fluoroscopy.

•

Echo fusion provides “real-time” feedback during complicated percutaneous procedures.

•

Echo fusion and 3D TEE imaging can be used to localize PVLs and guide intervention.

Percutaneous management of paravalvular leaks

Paravalvular leak (PVL) is a complication that occurs in 5-17% of patients after surgical prosthetic valve implantation. Whereas PVLs can be benign, some PVLs are associated with substantial morbidity and mortality. Percutaneous closure using occluders specifically designed to improve closure and reduce procedural complications has now become the first-line treatment for PVL. In this Review, we first detail the frequency and clinical consequences of PVL closure. The role of cardiac imaging in the assessment and management of PVL, including echocardiographic imaging and adjunctive techniques such as CT, is then discussed, together with important considerations for the percutaneous closure of PVL, such as access site and device selection. Finally, we summarize the clinical evidence for percutaneous closure of PVL, including large national registries from Ireland, Spain and the UK, as well as head-to-head data comparing this procedure with surgical closure.

Balloon aortic valvuloplasty: Treatment of rapid deployment aortic valve replacement complicated by a paravalvular leak

The Edwards Intuity Elite valve system was designed to facilitate minimally invasive surgery and streamline complex aortic valve replacements and has since gained more popularity. Despite the superior results shown with rapid deployment aortic valve replacement (RDAVR) utilizing this valve system, paravalvular leaks (PVL), as a complication, remains a concern. Currently, there is no universally agreed single treatment option. A 53-year-old male with a history of well-controlled diabetes mellitus and hypertension presented to the emergency room with a 1-month history of angina, syncope on exertion and dyspnea. On further workup, he was found to have severe aortic stenosis in the setting of a bicuspid aortic valve, with non-obstructive coronary artery disease. He proceeded to urgent RDAVR with a 23 mm Edwards Intuity Valve. Six months post-RDAVR he re-presented with dyspnea on exertion and near syncopal episodes. Postoperative transthoracic and transesophageal echocardiography revealed moderate to severe PVL posterior to the prosthetic aortic valve. Balloon valvuloplasty with a 25 mm True Balloon was performed. Resolution of the PVL was confirmed postprocedure both by angiography and echocardiography. The patient was followed for 1 year and remained symptom-free with evidence of mild PVL on surveillance echocardiography. In conclusion, multiple treatment options for RDAVR complicated by PVL exist; however mid to long-term outcome data are lacking. We presented one such case successfully treated with balloon aortic valvuloplasty.

Trans-catheter paravalvular leak closure: a single-centre experience

INTRODUCTION

A significant paravalvular leak (PVL) is estimated in at least 1-3% of patients undergoing surgical aortic and/or mitral valve replacement. Surgical repair of a PVL is associated with a 30-day mortality of approximately 10%. Percutaneous closure of PVL has emerged as an alternative to surgical repair.

AIM

We sought to examine the clinical outcomes of patients treated with percutaneous closure of PVL at an Irish tertiary referral centre.

METHODS

A prospective registry was used to record patient and procedural characteristics at the time of the PVL procedure. Medical records were retrospectively reviewed to assess clinical outcomes during the index hospitalisation and at follow-up.

RESULTS

A total of 26 PVL procedures were performed in 21 patients (mean age 68 ± 13 years, 76% male). Heart failure (HF), haemolysis (HL) or a combination of both was the presenting symptoms in 62%, 24% and 14% of patients, respectively. In the entire cohort, clinical success was achieved in 18 patients (86%). Clinical success was achieved more frequently when HF was the clinical indication compared to HL (100% versus 66%). Among patients presenting with isolated HF (n = 13), the mean NYHA class at baseline and follow-up was 2.5± 0.7 and 1.4± 0.7, respectively. Thirty-day mortality was 0%. There was one (3.8%) major adverse procedural complication (stroke). A total of six deaths (28%) occurred during follow-up (22 ± 13.4 months).

CONCLUSIONS

Patients with PVL represent a high-risk patient cohort. Percutaneous PVL offers a safe alternative to surgical PVL repair and appears particularly effective in those patients who present primarily with HF.

Retrospective analysis of single-center early and midterm results of transapical catheter-based mitral paravalvular leak closure with a purpose-specific device

Introduction

Due to the recent lack of definitions to establish the severity of paravalvular leak (PVL) and endpoints for its treatment, the effectiveness and safety of a new device for PVL closure have not been comprehensively analyzed.

Aim

To analyze a single center’s experience of mitral PVL closure in a surgical transapical catheter-based fashion with a purpose-specific device.

Material and methods

This is a retrospective cohort study of patients following transapical catheter-based mitral PVL closure with a purpose-specific device. Data were analyzed at baseline, perioperatively, at discharge, at six months and annually after the procedure.

Results

Nineteen patients underwent surgical transapical catheter-based mitral PVL closure with the Occlutech PLD Occluder. Mean follow-up time was 20 ±7 (range: 9–33) months. The patients’ mean age was 64 ±7 years, and 11 (58%) were male. Technical, device and individual patient success at follow-up was achieved in 18 (95%), 16 (84%) and 16 (84%) patients respectively. Median intensive therapy unit stay was one day (1–4) and mean hospital stay was 11 ±4 days. A reduction of paravalvular regurgitation to a mild or lesser degree was achieved in 18 (95%) patients. There were no strokes or myocardial infarctions at follow-up. There were no deaths at 30 days after the procedure. One (5%) patient expired due to progression of heart failure 12 months after surgery. None of the patients required immediate conversion to full sternotomy.

Conclusions

Surgical transapical catheter-based mitral PVL closure with the Occlutech PLD Occluder is a safe and clinically effective treatment.

Closure of mitral paravalvular defects without performing an arteriovenous loop: a case series of fourteen patients

Introduction

The arteriovenous (AV) loop is recommended when further support is needed during paravalvular leak (PVL) closure.

Aim

We report the feasibility and safety of mitral PVL closure without constructing an AV loop, based on a single-centre experience.

Material and methods

Fourteen patients with mitral valve replacement (MVR) who had New York Heart Association (NYHA) class III-IV dyspnoea or NYHA class II symptoms with significant haemolytic anaemia caused by severe or moderate-to-severe paravalvular regurgitation and who underwent transcatheter PVL closure (TPVLC) between May 2014 and February 2017 were enrolled.

Results

In total, 15 PVL procedures and 19 device deployments were performed. The patients had one (n = 10), three (n = 1) or four (n = 1) devices for closure at the time of the procedure; one patient had two devices from two procedures at different times with different access ways. Nineteen devices (10 (66.6%) via transseptal access; 4 (26.6%), transapical access; and 1 (6.6%), retrograde access) were deployed successfully without making an AV loop.

Conclusions

The TPVLC is a less invasive and effective alternative to surgery in symptomatic patients with significant PVLs and high operational risks. The success rates are satisfactory, with improving techniques and devices. Procedural success without using an AV loop can be achieved with reduced costs, fluoroscopic times and complications.

Comparison of transcatheter and surgical treatment of paravalvular leak: Results from a 5-year follow-up study

OBJECTIVE

This study aimed to compare the efficacy and safety of two different treatments of paravalvular leak (PVL).

BACKGROUND

PVL is a common complication after surgical valve replacement. Re-operation is associated with high mortality, morbidity, and risk of re-leak. Catheter-based repair has emerged as a promising new therapy.

METHODS AND RESULTS

Eighty-seven consecutive patients with symptomatic PVL received either transcatheter (n = 46) or surgical (n = 41) treatment at Shanghai Chest Hospital between January 2009 and December 2015.The procedural and clinical success rates were similar between the transcatheter group and the surgical group (82.6 vs. 90.2%; P = 0.30; and 69.5 vs. 73.0%; P = 0.71, respectively). There were fewer in-hospital total major adverse events in the transcatheter group (56.09 vs. 17.39%; P < 0.001), and transcatheter repair was more cost-effective, with fewer blood transfusions, shorter procedure durations, shorter hospital stays, and less expenditure. However, there were six cases of hemolysis aggravation in the transcatheter group (13.04%). The 5-year overall survival rates after transcatheter and surgical repair were 74.39 and 71.95% (P = 0.45), respectively, and the cardiac-related survival rates were 84.08 and 74.72% (P = 0.19), respectively.

CONCLUSION

Transcatheter and surgical repairs are both effective treatments for selected patients with PVL. And, transcatheter closure seems to be safer and more cost-effective. Nonetheless, this new treatment may be risky for post-procedure hemolysis when unsuitable devices are used.

Multi-Modality Imaging in the Evaluation and Treatment of Mitral Regurgitation

OPINION STATEMENT

Mitral regurgitation (MR) is frequent and associated with increased mortality and morbidity when severe. It may be caused by intrinsic valvular disease (primary MR) or ventricular deformation (secondary MR). Imaging has a critical role to document the severity, mechanism, and impact of MR on heart function as selected patients with MR may benefit from surgery whereas other will not. In patients planned for a surgical intervention, imaging is also important to select candidates for mitral valve (MV) repair over replacement and to predict surgical success. Although standard transthoracic echocardiography is the first-line modality to evaluate MR, newer imaging modalities like three-dimensional (3D) transesophageal echocardiography, stress echocardiography, cardiac magnetic resonance (CMR), and computed tomography (CT) are emerging and complementary tools for MR assessment. While some of these modalities can provide insight into MR severity, others will help to determine its mechanism. Understanding the advantages and limitations of each imaging modality is important to appreciate their respective role for MR assessment and help to resolve eventual discrepancies between different diagnostic methods. With the increasing use of transcatheter mitral procedures (repair or replacement) for high-surgical-risk patients, multimodality imaging has now become even more important to determine eligibility, preinterventional planning, and periprocedural guidance.

Hybrid Surgery Options for Complex Clinical Scenarios in Adult Patients with Congenital Heart Disease: Three Case Reports

The strategy for the management of adult patients with congenital heart disease (CHD) often represents a challenge for cardiac surgeons and cardiologists due to complex anatomy, wide range of clinical presentations, and a high-risk profile. However, hybrid approach may represent an attractive solution. We report three cases of adult patients previously operated for CHD and recently treated with a hybrid approach in our institution. Case 1: a 76-year-old woman with permanent atrial fibrillation, lung disease, chronic kidney disease, microcytic anemia, and type II diabetes mellitus, previously operated for atrial septal defect closure and pulmonary valvotomy, presented with severe pulmonary regurgitation and advanced right ventricular failure. In order to minimize the surgical risk, a hybrid approach was used: an extensive right ventricular outflow tract (RVOT) plication was followed by implantation of an Edwards Sapien XT prosthesis in the RVOT through the right ventricular apex, without cardiopulmonary bypass. Case 2: a 64-year-old man with previous atrial septum excision and pericardial baffle for partial anomalous pulmonary venous drainage with intact interatrial septum, presented with worsening dyspnea, right ventricular failure, and pulmonary hypertension caused by baffle stenosis. His comorbidities included coronary artery disease, atrial flutter, and previous left pneumonectomy. After performing a redo longitudinal median sternotomy, a 20-mm stent was implanted in the baffle with access through the superior vena cava. Case 3: a 50-year-old man, with previous atrioventricular septal defect repair, followed by mitral valve replacement with a mechanical prosthesis, subsequently developed a paravalvular leak (PVL) with severe mitral regurgitation and severe left ventricular dysfunction. He underwent a transapical PVL device closure with two Amplatzer Vascular Plugs. In our opinion, hybrid surgery is a promising therapeutic modality that increases the available treatment options for this patient population. A multidisciplinary and patient-tailored approach is crucial in these complex clinical scenarios.

Novel Solutions Applied in Transseptal Puncture: A Systematic Review

Access to the left atrium is required for several minimally invasive cardiac interventions in the left heart. For this purpose, transseptal puncture (TSP) technique is often performed, perforating the atrial septum under fluoroscopic or/and ultrasound imaging guidance. Although this approach has been used for many years, complications/failures are not uncommon mainly in patients with abnormal atrial anatomy and repeated TSP. Thus, this study presents an overview of methods and techniques that have been proposed to increase the safety and feasibility of the TSP. A systematic review of literature was conducted through the analysis of the articles published between 2008 and 2015. The search was performed in PubMed, Scopus, and ISI Web of Knowledge using the expression “transseptal puncture.” A total of 354 articles were retrieved from the databases, and 64 articles were selected for this review. Moreover, these 64 articles were divided into four categories, namely: (1) incidence studies, (2) intraprocedural guidance techniques, (3) preprocedural planning methods, and (4) surgical instruments. A total of 36 articles focused on incidence studies, 24 articles suggested novel intraprocedural guidance techniques, 5 works focused on preprocedural planning strategies, and 21 works proposed surgical instruments. The novel 3D guidance techniques, radio-frequency surgical instruments, and pre-interventional planning approaches showed potential to overcome the main procedural limitations/complications, through the reduction of the intervention time, radiation, number of failures, and complications.

Surgical Transapical Approach for Prosthetic Mitral Paravalvular Leak Closure: Early Results

The objective is to demonstrate safety and early clinical results of surgical transapical closure of paravalvular leaks (PVLs) following mitral valve replacement in significant regurgitation. Between March 2014 and February 2015, 12 patients (mean age 52.1 ± 6.0 years, 66.6% male) with severe symptomatic mitral PVLs (n = 13) underwent surgical transapical closure procedure through left mini-thoracotomy. All patients were in NYHA functional class III-IV and median logistic EuroSCORE was 24.2 ± 6.4% (range, 13.5-34.6%). Indications were heart failure (n = 10) and symptomatic hemolysis (n = 2) due to severe mitral regurgitation (MR). Amplatzer Vascular Plug-III devices (n = 9) were used for smaller and regular defects; whereas Atrial Septal Defect closure devices (n = 4) were used for larger defects. Technical success was achieved in 10 (83.3%) patients. One (8.5%) patient with 2 + MR was treated medically. A patient with residual 4 + MR underwent re-operation. There was no procedure-related complication including mortality, device migration, embolization, or cardiac laceration. Mean procedure and fluoroscopy times were 166.4 ± 39.5 (range, 90-210) and 25.7 ± 17.3 (range, 16-64) minutes, respectively. The mean intensive care and hospital stays were 2.1 ± 1.3 and 10.3 ± 6.5 days, respectively. Clinical efficacy was achieved in 9 (75%) of 12 patients at early follow-up of 8.5 ± 2.1 months. NYHA status was class II in two patients, and no hemolytic anemia was diagnosed. Echocardiographic studies revealed a significant reduction of preoperative MR (3-4+) to less than 1+ MR after operations (P < 0.05). Surgical transapical approach to PVL closure is a safe and effective procedure following mitral valve replacement. Early results show that this procedure can be an alternative to re-operation for high-risk patients. Further studies are needed to prove its effectiveness in the long term.

Hemolysis after percutaneous paravalvular leak repair

Paravalvular leak is a common complication after surgical mitral valve replacement. Surgically implanted prosthetic valves are complicated with paravalvular leaks in 17%.¹ Surgical closure of paravalvular leaks is the most common therapy for these defects. Percutaneous closure is an alternative to repeat surgery for a selected high-risk population. We present a case of a patient who developed severe haemolytic anaemia and secondary renal failure after partially successful percutaneous closure of paravalvular leakage of a prosthetic mitral valve. The assumption is that the combination of a metallic foreign body and high shear stress caused haemolysis by damaging red blood cells.

Percutaneous Device Closure of Paravalvular Leak: Combined Experience From the United Kingdom and Ireland

BACKGROUND

Paravalvular leak (PVL) occurs in 5% to 17% of patients following surgical valve replacement. Percutaneous device closure represents an alternative to repeat surgery.

METHODS

All UK and Ireland centers undertaking percutaneous PVL closure submitted data to the UK PVL Registry. Data were analyzed for association with death and major adverse cardiovascular events (MACE) at follow-up.

RESULTS

Three hundred eight PVL closure procedures were attempted in 259 patients in 20 centers (2004-2015). Patient age was 67±13 years; 28% were female. The main indications for closure were heart failure (80%) and hemolysis (16%). Devices were successfully implanted in 91% of patients, via radial (7%), femoral arterial (52%), femoral venous (33%), and apical (7%) approaches. Nineteen percent of patients required repeat procedures. The target valve was mitral (44%), aortic (48%), both (2%), pulmonic (0.4%), or transcatheter aortic valve replacement (5%). Preprocedural leak was severe (61%), moderate (34%), or mild (5.7%) and was multiple in 37%. PVL improved postprocedure (P<0.001) and was none (33.3%), mild (41.4%), moderate (18.6%), or severe (6.7%) at last follow-up. Mean New York Heart Association class improved from 2.7±0.8 preprocedure to 1.6±0.8 (P<0.001) after a median follow-up of 110 (7-452) days. Hospital mortality was 2.9% (elective), 6.8% (in-hospital urgent), and 50% (emergency) (P<0.001). MACE during follow-up included death (16%), valve surgery (6%), late device embolization (0.4%), and new hemolysis requiring transfusion (1.6%). Mitral PVL was associated with higher MACE (hazard ratio [HR], 1.83; P=0.011). Factors independently associated with death were the degree of persisting leak (HR, 2.87; P=0.037), New York Heart Association class (HR, 2.00; P=0.015) at follow-up and baseline creatinine (HR, 8.19; P=0.001). The only factor independently associated with MACE was the degree of persisting leak at follow-up (HR, 3.01; P=0.002).

CONCLUSION

Percutaneous closure of PVL is an effective procedure that improves PVL severity and symptoms. Severity of persisting leak at follow-up is independently associated with both MACE and death. Percutaneous closure should be considered as an alternative to repeat surgery.

Two-Year Follow Up After Surgical Versus Percutaneous Paravalvular Leak Closure: A Non-Randomized Analysis

BACKGROUND

Percutaneous closure of paravalvular leak (PVL) has emerged as an alternative treatment. Predictors of survival and procedural success are unknown.

OBJECTIVES

To review our experience in the treatment of PVL and evaluate efficacy, mortality, predictors of success, and outcomes.

METHODS

Retrospective review of percutaneous PVL procedures between years 2008 and 2014. Survival and results were compared with a control cohort of surgical patients.

RESULTS

Percutaneous closure was attempted in 51 patients. The surgical group had 36 patients. Defects were perimitral in 67 patients (77%). Mean follow-up (FU) was 784.5 days. After propensity score analysis in-hospital mortality was higher in the surgical group (30.6% vs. 9.8%, OR 6, P 0.01). Clinical improvement was higher in the percutaneous group (71.4% vs. 36.4%, P 0.002). Multivariate analysis showed normal creatinine (OR 15, P < 0.001) as independent predictor of clinical improvement. For the composite end-point of all-cause mortality or readmission, older age (OR 10.7, P 0.001), renal failure, (OR 18, P < 0.01), poor functional class and the absence of clinical improvement (OR 3.9, P < 0.001) were related with a higher risk. There were no differences in survival free from the composite end-point according to the treatment received (surgical or percutaneous).

CONCLUSION

Percutaneous PVL closure has a reasonable rate of success and low complication rates, and results compare favorably with surgical treatment. Older patients and those with poor functional class or renal failure (RF) showed a worse prognosis even after a successful closure. © 2016 Wiley Periodicals, Inc.

Recent developments in percutaneous mitral valve treatment

In recent years, various percutaneous techniques have been introduced for the treatment of mitral regurgitation (MR), including direct leaflet repair, annuloplasty and left ventricular remodeling. Percutaneous mitral repair targets both primary degenerative and secondary mitral valve regurgitation and may be considered in selected high-surgical-risk patients. The assessment of mitral functional anatomy by echocardiography and computed tomography is crucial when selecting the appropriate repair strategy, according to the regurgitant valve lesion and the surrounding anatomy. The ongoing clinical use of new devices in annuloplasty and percutaneous mitral valve replacement is a promising new scenario in the treatment of MR that goes beyond the conventional surgical approach.

Surgical treatment of paravalvular leak: Long-term results in a single-center experience (up to 14 years)

OBJECTIVES

The aim of this study is to report the long-term outcomes (median follow-up time, 7 years; range, 1 month to 14 years) of patients who underwent surgery for paravalvular leak in our single-center experience.

METHODS

From October 2000 to November 2007, 122 consecutive patients underwent surgery for symptomatic paravalvular leak (40 patients with aortic paravalvular leak; 82 with mitral paravalvular leak). In 7 patients (5.7%, all mitral), surgery was performed on the beating heart through a right thoracotomy. In 35% of patients, multiple paravalvular leaks were present.

RESULTS

The mean age of patients was 62 ± 11 years, and European System for Cardiac Operative Risk Evaluation II was 7.2% ± 6%. Most of the patients were in New York Heart Association functional class III or IV (60%). Symptomatic hemolysis was present in 31% of the patients, and 41% of the patients had more than 1 previous cardiac operation. Paravalvular leak repair was feasible in 79 patients (65%), whereas in 43 patients (35%) prosthesis re-replacement was required. Thirty-day mortality was 10.7% (13/122 patients; 5% for aortic paravalvular leak and 13% for mitral paravalvular leak; P = .1); 2 patients (1.6%) with residual severe mitral paravalvular leak underwent successful redo surgery before discharge. Median length of stay was 7 days. Overall actuarial survival was 39% ± 6% at 12 years; freedom from cardiac death was 54% ± 7% at 12 years. Only 1 patient underwent redo surgery during follow-up. Multivariable analysis identified preoperative chronic renal failure (hazard ratio, 2.6; 95% confidence interval, 1.4-4.9; P = .03) and more than 1 previous cardiac reoperation (hazard ratio, 2.3; 95% confidence interval, 1.3-4; P = .03) as independent predictors of death at follow-up.

CONCLUSIONS

The operative mortality of surgical treatment of paravalvular leak is still high. Long-term outcomes remain suboptimal in these challenging patients, especially in the presence of multiple previous cardiac operations and associated co-pathologies. These results support the importance of alternative therapeutic options.

Transcatheter mitral paravalvular leakage closure: A beautiful last resort

We describe a case of a 54-year-old patient with rheumatic heart valve disease who was treated with double valve replacement (both aortic and mitral) twice. Two months after the second operation she developed a severe mitral paravalvular leakage (PVL) leading to cardiogenic shock for which she was hospitalized in the intensive care unit. Multiple weaning efforts proved to be unsuccessful because of persistent hemodynamic instability caused by the severe PVL. Since re-redo cardiac surgery would have meant an unacceptable high peri-operative risk it was decided in the heart team to close the PVL by a transcatheter technique. This was done successfully and led to a spectacular hemodynamic improvement. Just 24 h after closure of the PVL she could be discharged from the intensive care unit and the day after the procedure she came walking into the echocardiography laboratory for an echocardiographic evaluation. This case demonstrates not only the feasibility of transcatheter closure of a PVL but also that this can be a true life-saving act. <Learning objective: This case emphasizes that refractory heart failure can be a hard indication for closure of a PVL given the fast and complete clinical recovery after closure of the defect. Furthermore, it demonstrates the feasibility and the efficacy of transcatheter PVL closure, even when multiple devices have to be used to close the leak properly avoiding the risks inherent to redo cardiac surgery.>.