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

Chennian Xu, Yang Liu, Mengen Zhai, Ping Jin, Lanlan Li, Yanyan Ma, Jian Yang, Chennian Xu, Yang Liu, Mengen Zhai, Ping Jin, Lanlan Li, Yanyan Ma, Jian Yang

Abstract

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&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&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&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&3D printing had shorter procedural times compared with those guided by TTE [(61.2 ± 23.4) vs. (105.7 ± 53.9) min, p < 0.05]. The fluoroscopic time was also shorter for operations guided by TEE&3D printing compared with those guided by TTE alone [(18.5 ± 11.4) vs. (27.3 ± 5.6) min, p < 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].

Keywords: follow-up; paravalvular leak; three-dimensional printing; transcatheter closure; transesophageal echocardiography.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Xu, Liu, Zhai, Jin, Li, Ma and Yang.

Figures

FIGURE 1
FIGURE 1
Patient flow diagram of the transthoracic echocardiographic (TTE) group and the transesophageal and 3-dimensional group.
FIGURE 2
FIGURE 2
The TTE and transesophageal echocardiographic (TEE) scans taken before the procedure. (A) TEE shows the aortic paravalvular leakage (PVL) before the procedure. (B) 3-Dimensional (3D)-TEE shows the aortic PVL before the procedure. (C) 3D-TEE shows the mitral PVL before the procedure. (D) The mitral PVL as seen on the TEE scan. (E) The mitral PVL as seen on the TTE scan. (F) The mitral PVL was as seen on TTE.
FIGURE 3
FIGURE 3
Preoperative 3D printing model and preoperative simulation in vitro. (A) The preoperative plan was simulated in an external phantom using the 3D printing model. (B) The mitral PVL and its position as seen in the 3D printing model. (C) The implantation of the occluder in the mitral PVL was performed retrogradely via the femoral artery in the 3D printing model. (D) The 3D model shows the situation after the occluder was implanted in the mitral PVL.
FIGURE 4
FIGURE 4
Angiography profiling of the transcatheter closure of an aortic mechanical PVL. (A) Ascending aorta angiogram to profile para-aortic regurgitation. (B) Retrograde crossing of the PVL with a guidewire. (C) An occluder placed at the position of the PVL. (D) Ascending aorta angiogram after deployment. (The black arrow indicates the PVL. The white arrow indicates the occluder).
FIGURE 5
FIGURE 5
Angiography during the transcatheter procedure of mitral mechanical PVL closure via multiple approaches. (A–C) Transfemoral retrograde approach. (A) Left ventricular angiogram to profile paramitral regurgitation. (B) Retrograde crossing of the PVL with the guidewire. (C) Occluder placed at the position of the PVL. (D–F) Arteriovenous wire loop approach. (D) The retrograde crossing of the PVL with the guidewire followed by a transseptal puncture. (E) The sheath is advanced into the left ventricle from the femoral vein via the arteriovenous wire loop. (F) An occluder is placed at the position of the PVL. (G–I) Mini-invasive transapical approach. (G) The transapical access is obtained with a 6 Fr sheath. (H) The mitral PVL crossed retrogradely with the guidewire. (I) The occluder is deployed. (The black arrow indicates the PVL. The white arrow indicates the occluder).
FIGURE 6
FIGURE 6
Echocardiograms taken during the follow-up period. (A) TTE shows the mitral PVL after the procedure. (B) TTE shows the mitral PVL closed with the occluder. (C) The mitral PVL is closed with 2 occluders with TEE guidance. (D) The mitral PVL is closed with 2 occluders under 3D TEE guidance.
FIGURE 7
FIGURE 7
The 1-year follow-up of TTE and transesophaeal echocardiography and the 3-dimensional (TEE&3D) groups. (A) Improvement of the New York Heart Association functional class during the 1-year follow-up period. (B) The left ventricular ejection fraction during the 1-year follow-up period (TEE&3D vs. TTE, p > 0.05). (C) NT-proBNP levels during the 1-year follow-up period (TEE&3D vs. TTE, p > 0.05). (D) Indirect bilirubin levels during the 1-year follow-up period (TEE&3D vs. TTE, p > 0.05).

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Source: PubMed

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