Transcatheter Closure of Mitral Paravalvular Leak via Multiple Approaches

Yang Liu, Chennian Xu, Peng Ding, Jiayou Tang, Ping Jin, Lanlan Li, Min Chen, Xin Meng, Hongliang Zhao, Jian Yang, Yang Liu, Chennian Xu, Peng Ding, Jiayou Tang, Ping Jin, Lanlan Li, Min Chen, Xin Meng, Hongliang Zhao, Jian Yang

Abstract

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.

Conflict of interest statement

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

Copyright © 2021 Yang Liu et al.

Figures

Figure 1
Figure 1
Protocol strategy for the different procedures.
Figure 2
Figure 2
A 3D printing model clearly shows the location and surrounding structures of mitral paravalvular leakage.
Figure 3
Figure 3
Angiogram taken during the transcatheter procedure of mitral PVL closure via a transfemoral retrograde approach. (a) Left ventricular angiogram to profile the paramitral regurgitation. (b) Retrograde crossing of the paravalvular leak with the guidewire. (c) The introducer sheath was advanced into the left atrium. (d) The occluder device was placed at the position of the paravalvular leak. (e) The occluder device was deployed. (f) Left ventricular angiogram after deployment. The black arrow indicates the PVL. The white arrow indicates the occluder.
Figure 4
Figure 4
Angiogram taken during the transcatheter closure of the mitral PVL closure via an anterograde transseptal approach and arteriovenous wire loop approach. (a) The femoral venous access was followed by a transseptal puncture. (b) The introducer sheath was advanced into the left ventricle from the femoral vein. (c) The occluder was delivered into the left ventricle. (d) The occluder was deployed. (e) The transseptal puncture was followed by snaring the wire for setting up the arteriovenous loop. (f) The introducer sheath was advanced into the left ventricle via the arteriovenous loop. (g) The occluder was partially placed at the position of the paravalvular leak. (h) The occluder was deployed. The black arrow shows the paravalvular leak. The white arrow shows the occluder.
Figure 5
Figure 5
Closure of a mitral paravalvular leak (PVL) via the transapical approach. (a–d) The transcatheter closure of the mitral PVL via a minimally invasive transapical approach. (a) The transapical accesses were obtained by placement of a 6 Fr sheath. (b) The mitral PVL was crossed retrogradely. (c) The introducer sheath was advanced into the left atrium. (d) The occluder was deployed. (e–h) Transcatheter closure of the mitral PVL via a transapical puncture and arteriovenous loop. (e) Coronary angiogram to confirm the location of the left anterior descending artery. (f) A 5 Fr sheath was placed into the left ventricle percutaneously. (g) The transseptal puncture was followed by snaring the wire to establish an arteriovenous loop. (h) The occluder was placed at the position of the PVL followed by a left ventricular angiogram. The black arrow indicates the PVL. The white arrow indicates the occluder.
Figure 6
Figure 6
The 1-year follow-up results.
Figure 7
Figure 7
The 3-dimensional echocardiograms and computed tomography angiograms taken before the procedure and during the follow-up period. (a) Three-dimensional transesophageal echocardiography shows the mitral paravalvular leak (PVL) before the procedure. (b) Three-dimensional transesophageal echocardiography shows the mitral PVL closed with the occluder. (c) The mitral PVL was closed with the occluder (sagittal view). (d) The mitral PVL was closed with the occluder (axial view). The yellow arrow indicates the PVL. The red arrow indicates the occluder.
Figure 8
Figure 8
The 3D printing model of patients was made based on the postoperative CT results. The operator observed the position of the occluder device in vitro and evaluated the results of the operation.

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Source: PubMed

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