leak closure

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BACKGROUND The incidente of paravalvular leaks is variable

( from 2% to 7% ). It approaches 30% in those

operated because of paravalvular leak.

Surgical approach has been traditionally

considered the treatment of choice

In the past years an alternative therapeuticapproach has been sought


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Therapeutic Options

Medical treatment of hemolysis, CHF or both

Surgical repair of perivalvular leak #

Surgical replacement with a new valve #

Percutaneous repair of perivalvular leak ##

# Echevarria et al. Eur. Cardio Surg. 1991; 523-26.## -


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Kim et al. JACC Interv 2009; 2: 81-90


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TECHNIQUES

ortic Leak

iagnosis : Angiography and

Echocardiography

ascular access: Femoral or Brachial


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Aorta

Catheter

Guide Wire


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TECHNIQUES

Mitral Leak:

Diagnosis:

2D Echocardiography for diagnosis andlocation *

3D Echocardiography for size and shape **

Pre-procedural planing with rapidprototyping***

*Cortes et al. Am J Cardiol 2008; 101: 382-6 **Marx et al. Cardiol Clin 2007; 25:357-65


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Mitral leak

Right femoral vein and right/ left femoralartery approach

Transeptal puncture

Anterograde or retrograde leak approach

Amplatzer sheath to LV throught the leak

TEE procedural guidance

Amplatzer occluder positioning and release


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Mitral Leak

Transeptal puncture can be difficult andsometines requires SVC approach

Leak access: Antegrade or retrograde

Leak crossing: Terumo wire through IM(anterior), multipurpose (posterior) or RCA

( medial) catheters in antegrade approach

Terumo wire through multipurpose catheter inretrograde approach


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Result post procedure


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MITRAL PERIVALVULAR LEAKS

1. Use inflated Swan-Ganz catheter to undo LAloop and exchange high support wire

2. LA-LV-Ao with hydrophilic wire for wireexchange

3. Double transeptal for dual leak closure

4. Mid opening of the Amplatzer distal disk toavoid valve mechanism interference

Loosen up your imagination

(Special tricks)


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2D- 3D TEE Echocardioghraphy

Define leak anatomy

Guide leak passage of wire and device

Assess procedural result


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SURGICAL EXPERIENCE

136 Re-interventions (107 because ofparavalvular leak)

Operative mortality : 6.6%

Perioperative stroke : 5.1%

Freedom from repeated paravalvular leak :63%

K-M 10-year survival : 30%

Akins et al. J Heart V. Dis 2005; 14: 792-799


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PERCUTANEOUS RESULTS

Published reports : 10 papers , 52 patientsTechnical success : 44/52 ( 86% )

Clinical success : 28/52 ( 53%)

JACC 1992; 20:1371. CCI: 2005;65:69. JHVD 2007; 16:305. CCI 2000; 49:64. CCI2001; 54: 234. CCI 2007 ; 69: 708. CCI 2007; 70:815.

Kim et al..JACC, CCV Interventions 2009; 2: 81-90


17/28Kim et al. JACC Interv 2009; 2:81-90


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Personal experience

Procedures : 127

Mitral : 103

Aortic : 21

Mitro-aortic : 3

Devices : Duct occluder : 96. VPIII: 31


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AORTIC PARAVALVULAR LEAKS

ResultsProcedural success 16/17

Clinical improvement 14/17

Mortality ( > 3mo ) 1/17

Surgery ( > 3 mo ) 2/17


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MITRAL PARAVALVULAR LEAK

RESULTS N= 79Procedural success 60 /79 (76%)

Mortality( > 3 m ) 5/79 (6%)

Surgery ( > 3m ) 4/79 (5%)

Clinical improvement 55/79 ( 70%)


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AMPLATZER Vascular Plug III

Under review

Double-lobed, multi-

layer and oval-shaped

Extended rims for better

apposition in high flow

situations.

Faster occlusion time


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EXPERIENCE WITH THE NEW

DEVICE VP III

(January August 2009)Hospital Clinico San Carlos

Patients = 26, Procedures = 31 Devices =29)


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BASELINE

CHARACTERISTICSN= 26

Age 6311 yrs

Gender 14 male, 12 Female

Leak Location 22 Mitral, 3 Aortic, 1 Aorto mitral

Valve type 24 Mechanical, 3 Biological


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PROCEDURAL

CHARACTERISTICSN= 31

Vascular Access Femoral 29, Brachial 2

Loop ( A-V, A-A, V-V ) 23 (75%)

Delivery catheter AGA sheath ( 6-7 Fr.): 23Sheathless GC (6.5Fr): 3Destination GC ( 7Fr) : 2Heart Trail ( 6 Fr): GC

Device size 8/4 mm: 19;6/3 mm : 9;

10/5 mm :1;

12/5 : 1;

14/5: 1


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PROCEDURAL RES ULTSN= 31

Procedural success 28/31 ( 90 %)

Patient success 26/26 ( 100% )

Device success Complete closure : 17/29 ( 58% ),Partial closure ( 42%)

Complications : 2 pseudoaneurysms,

1 A-V fistula


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FUTURE DIRECTIONS

Better definition by different imagingmodalities

More experience with Rapid Prototyping

Improved lubrication of transporting sheathsto facilitate passage

Improve device design

Validate other options ( TRANSAPICALAPPROACH )


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CONCLUSIONS

The new VP III is anatomically and functionally moreadequate device to treat paravalvular leaks

The treatment of mitral paravalvular leaks is still aclallanging procedure

In most cases the retrograde access and an arterio-venous loop is an easier and faster way to repair mitral

paravalvular leaks

3D TEE is of great help to design and guide the procedure

Percutaneous repair of paravalvular leaks should be inmy opinin the first option of treatment

leak closure

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