How to Address Paravalvular Leak 6 Ways to Sunday
Morgan H. Randall, Calvin Choi, Thomas M. Beaver
University of Florida, Gainesville, FL, USA
OBJECTIVE: Recognize the indications and benefits of using multiple vascular occlusive devices percutaneously in treating paravalvular leak (PVL).
METHODS: A 76-year-old male with severe bioprosthetic mitral valve stenosis and PVL presented with shortness of breath and anemia. In 2006 he had mitral valve replacement with a 27mm Perimount (Edwards Lifesciences, Irvine, CA) for endocarditis. In 2020 he developed NYHA Class IV Congestive Heart Failure with dyspnea on exertion and was unable to ambulate. TEE showed an immobile prosthetic leaflet and PVL; and he underwent transcatheter valve-in-valve placement using a 29 mm Sapien 3 bioprosthetic valve (Edwards Lifesciences, Irvine, CA). The patient improved immediately and was able to ambulate, but was noted to have significant residual PVL. His heart failure symptoms progressed and therefore he was taken back to the operating room for percutaneous PVL closure. RESULTS: Via the right femoral vein and right atrium, a transseptal puncture was performed using a Brockenbrough needle under transesophageal echocardiographic (TEE) and fluoroscopic guidance. Catheter was exchanged in the left atrium to an Agilis steerable catheter (Abbott, Abbott Park, IL), which was used to position a guidewire (Terumo Interventional Systems, Somerset, NJ) across the PVL. A 5 FR delivery sheath was advanced with an Amplatz Duct Occluder II (Abbott, Abbott Park, IL) along with a separate 0.018 guide buddy wire, which was used to re-cross the PVL and deliver additional Occluder II devices in a sequential manner under TEE guidance. Due to the crescent shape of the patientís PVL along P1 to P3, a total of n=6 Occluder II devices (two 4x6mm, two 5x6mm, two 6x6mm) were required to achieve the desired results.
CONCLUSIONS: After closure of the patientís PVL, the patientís functional status improved. This particularly complex transcatheter intervention highlights the importance of a multidisciplinary approach, multi-modality techniques and the technical skills required to address prosthetic valve failure and PVL in high-risk patients.