Percutaneous closure of paravalvular leaks EULOGIO GARCIA MD MADRID ~ SPAIN

BACKGROUND The incidente of paravalvular leaks is variable ( from 2% up to 17% ). More frequent in mechanical valves. Surgical approach has been traditionally considered the treatment of choice In high risk surgical patients an alternative approach has been sought Leaks

Percutaneous Closure Experience Percutaneous closure of aortic leak with Amplatzer Duct Occluder * Percutaneous closure of paravalvular mitral leak using an ASD occluder ** Perctuaneous closure with Radskind device *** Percutaneous closure of mitral leak with Amplatzer duct occluder **** Coil embolization of mitral leak ***** *Webb et al. Am J Cardiol 2005; 65: 69-72 ** Pate atb al. Can J Cardiol 2004; 20: 452-55 *** Hourihan et al. JACC 1992; 20: 1371-77 **** Kort et al. CCI 2004; 61:548-551 *****Moscucci et al. 2001; 104; 85-86 Leaks

Ductus Amplatzer System

Patient Selection Congestive Heart Failure Hemolytic anemia Other prosthetic valve History of mediastinitis Euroscore > 6 Leaks

AORTIC PERIVALVULAR LEAKS General considerations Most frequent locations : Left and noncoronary sinus Right brachial access : more adequate to available technology Echocardiography : most important before, not during the procedure Access through leak : multipurpose and hydrophilic wire Size of device : important not exceed adequate size ( average 6-8 mm) Leaks

AORTIC PARAVALVULAR LEAKS Demographics Age Male gender (%) Time since 1st surgery NYHA III or IV (%) N= 15 62±17 yrs 77 10 yrs 56% Leaks

AORTIC PARAVALVULAR LEAKS Results Procedural success 14/15 Clinical improvement 12/15 Mortality ( > 3mo ) 1/15 Surgery ( > 3 mo ) 2/15 Leaks

PROCEDURE ( Ao Leak ) Right braquial approach Aortogram Left ventricular access through the leak using a Terumo wire Multippourpose catheter to LV High support exchange wire Amplatzer sheath Amplatzer duct occluder device deployment Aortogram Leaks

Aorta Catheter Guide Wire Leaks

MITRAL PERIVALVULAR LEAKS General considerations Location : Careful analysis of leak location by TEE Transeptal : Difficulty increased by previous surgery Anticoagulation : Generous heavy manipulation in LA TEE : Important coordination echocardiographist-operator Leaks

Mitral leak Right femoral vein and left femoral artery approach Transeptal puncture Anterograde or retrograde leak approach Amplatzer sheath to LV throught the leak TEE procedural guidance Amplatzer duct occluder positioning and release Leaks

Device deployment Leaks

Device release

Result post procedure

MITRAL PERIVALVULAR LEAKS Tips & Tricks Leak access : LA- LV Postero-septal: hydrophilic multipurpose and hydrophilic straight wire ( big loop in the roof of LA ) Antero-lateral: IMA catheter or Simmons ( head hunter ) Lateral: RCA catheter Leaks

MITRAL PERIVALVULAR LEAKS Tips & Tricks Retrograde: LV- LA Multiporpose hydrophilic and hydrophilic wire snare in LA establish arteriovenous loop. Leaks

MITRAL PERIVALVULAR LEAKS Loosen up your imagination (Special tricks) 1. Use inflated Swan-Ganz catheter to undo LA loop 2. LA-LV-Ao with hydrophilic wire for wire exchange 3. Double transeptal for dual leak closure 4. Mid opening of the Amplatzer distal disk to avoid valve mechanism interference Leaks

MITRAL PERIVALVULAR LEAKS Tips & Tricks Simultaneous retrograde aortic an mitral perivalvular leak closure Multiporpose hydrophilic catheter and wire through aortic leak exit from LW to LA Catheter from Ao-LV- LA ---Device deployment in mitral leak---device deployment in aortic leak. Leaks

MITRAL PERIVALVULAR LEAKS Tips & Tricks Simultaneous antegrade aortic an mitral perivalvular leak closure Multiporpose hydrophilic catheter and wire through mitral leak exit from LW to Ao Catheter from LA-LV- Ao ---Device deployment in aortic leak---device deployment in mitral leak. Leaks

6 month follow-up TEE Mitral valve: Mild valvular mitral regurgitation with no signs of perivalvular leak Aortic valve: Mild valvular aortic regurgitation with no signs of perivalvular leak Clinical symptoms Mild exercional dyspnea (NYHA II) No anemia

MITRAL PARAVALVULAR LEAKS Demographics ( 49 pts, 57 proc ) Age 63± 10 yrs Male gender 34 ( 69%) Time since 1st surgery NYHA III or IV 19 yrs 31 ( 64%) Leaks

MITRAL PARAVALVULAR LEAKS CLINICAL RESULTS Procedural success 32 /49 (66%) Mortality ( > 3 mo ) 5/49 (11%) Surgery ( > 3mo ) 4/49 (8%) Clinical improvement 30/49 ( 61%) Leaks

Conclusions Percutaneous repair of aortic paravalvular leaks is feasible in most patients Aortic paravalvular leak repair is not technically difficult and should be the first therapeutic option. Mitral paravalvular leak repair is technically demanding and can be contemplated in high risk surgical patients At this time there is not systematic procedural approach nor adequate device to repair these defects in a routine fashion. Every procedure is a la carte. Efforts should be made to design device (s) to adequately treat these leaks. Leaks

AMPLATZER Vascular Plug III Under review Double-lobed, multilayer and oval-shaped Extended rims for better apposition in high flow situations. Faster occlusion time