Canadian Journal of Cardiology
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(2014) 1.e1e1.e3 www.onlinecjc.ca
Case Report
Percutaneous Closure of a Small Posterior Mitral Paravalvular Leak in a Patient With Coexistent Monoleaflet Mechanical Aortic Valve Miroslava Stolcova, MD,a Italo Porto, MD, PhD,a,b Francesco Meucci, MD,a Giovanni Squillantini, MD,a and Gennaro Santoro, MDa a b
Interventional Cardiology Unit, Careggi Hospital, Firenze, Italy
Interventional Cardiology Unit, San Donato Hospital, Arezzo, Italy
ABSTRACT
RESUM E
Percutaneous closure of a paravalvular leak is a challenging procedure that often presents with multiple simultaneous hurdles. We report a case of percutaneous retrograde paravalvular leak closure in a patient with a coexistent monoleaflet mechanical aortic valve. The leak was crossed and occluded using a combination of techniques deriving from the coronary and peripheral angioplasty fields.
e d’une fuite paravalvulaire est un acte comLa fermeture percutane s. Nous plexe qui comporte souvent de multiples obstacles simultane e de fuite paravalvulaire par rapportons un cas de fermeture percutane trograde chez un patient ayant une valve aortique me canique voie re e d’un seul feuillet. La fuite a e te franchie et occluse en uticompose lisant une combinaison de techniques relevant du domaine de l’anriphe rique. gioplastie coronarienne et de l’angioplastie pe
Case Presentation A 50-year-old man who had undergone 3 previous valve proceduresda monoleaflet Medtronic Hall prosthesis (Medtronic, Minneapolis, MN) in the aortic position and a Sorin Bicarbon bileaflet valve (Sorin Group, Milan Italy) in the mitral positiond presented with a mitral paraseptal-posterior periprosthetic leak, causing severe hemolysis (Fig. 1 and ; view video online). Transcatheter closure with Video 1 antegrade access was planned. The procedure was performed under transesophageal echocardiographic guidance. During transeptal access, the interatrial septum was dilated with a 4 20 mm coronary balloon (TREK; Abbott Vascular, Abbott Park, IL) to allow the Mullins sheath to cross the fossa. Several antegrade leak engagement attempts with a 0.035-inch 260-cm angled-tip Glidewire (Terumo Medical, Tokyo, Japan) supported by various diagnostic catheters were unsuccessful because of its unfavourable position. Therefore, we switched to a retrograde approach. A 0.014-inch 300-cm guidewire (BALANCE MIDDLEWEIGHT, Abbott Vascular) supported by a 5F 150-cm Radifocus Glidecath (Terumo Medical) was advanced in the left ventricle (LV) across the aortic
; view prosthesis and crossed the leak (Fig. 2A and Video 2 video online). The patient did not experience any hemodynamic deterioration. A 5 60 mm Savvy over-the-wire dilatation catheter (Cordis, Bridgewater, NJ) was advanced through the leak and used to perform a transesophageal echocardiographically guided stop-flow occlusion test. The small tortuous anatomy of the leak ; view video online). was confirmed (Fig. 2B and Video 3 We then created an arteriovenous loop and crossed the leak in an antegrade fashion with a 4F multipurpose catheter, allowing a 0.035-inch AMPLATZ Superstiff wire (Boston Scientific, Natick, MA) to advance into the LV. A 7F JR guiding catheter (Vista Brite Tip; Cordis), which we planned to use to deploy the occluder, was advanced to the LV. Friction, however, was encountered, and a balloon-tracking technique was used, sliding the guiding catheter over the partially inflated 4 20 mm balloon across the leak (Fig. 1C ; view video online). At the end, an and Video 4 AMPLATZER Vascular Plug III (St Jude Medical, St Paul, MN), 10 5 mm, was successfully delivered to completely occlude the leak, with no interference with the valve (Fig. 1D ; view videos online). and Videos 5 and 6
Received for publication December 26, 2013. Accepted January 26, 2014.
Discussion Several hurdles had to be resolved to close the paravalvular leak in our patient. First, the small hole was in a difficult position and was best approached transapically or in a
Corresponding author: Dr Italo Porto, Cardiovascular Department, San Donato Hospital, Via Pietro Nenni, 52100, Arezzo, Italy. E-mail: [email protected] See page 1.e2 for disclosure information.
0828-282X/$ - see front matter Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2014.01.016
1.e2
Canadian Journal of Cardiology Volume - 2014
Figure 1. (A) Transesophageal-derived continuous-wave Doppler tracing (bottom part) of the regurgitant jet caused by the leak. (B) Colour Doppler image of the jet. (C) Location of the leak (red oval) in 3-dimensional surgical view AO, aorta; H, head; LAA, left atrial appendage; P, posterior; PA, pulmonary artery; R, right; RCA, right coronary artery. Modified from Ruiz et al.1 with permission from Elsevier.
retrograde fashion.1 Indeed, it is possible to establish the atrioventricular loop by exteriorizing the wire introduced through the LV apex from the venous access.2 However, we elected to avoid further surgical trauma to this young patient. It is generally accepted that crossing a mechanical valve with a catheter or a wire may result in valve dysfunction. Recently, 3 reports described crossing of bileaflet aortic prostheses: in an antegrade fashion with a 0.035-inch stiff guide wire2,3 and in a retrograde fashion with a 0.035-inch hydrophilic guide wire supported by a 5F catheter.4 A bileaflet valve has even been crossed with a partially opened AMPLATZER septal occluder.5 There is only 1 report3 of a monoleaflet valve crossed in an antegrade fashion with a 0.035-inch wire. No reports exist on retrograde crossing. We used a flexible 5F catheter supporting a 0.014-inch wire and did not observe any hemodynamic deterioration, in contrast to other studies.2-5 Paradoxically, the interaction of a catheter with a monoleaflet valve might be better tolerated than with a bileaflet valve because of the size of the larger orifice in such valves. Other problems of the case were a thick postsurgical interatrial septum and the small dimensions of the paravalvular leak, which were solved by using a coronary balloon to dilate the septum and a peripheral balloon to dilate the leak. Such a technique could be useful in small leaks producing significant compromise. Another important tip is balloontracking to facilitate the crossing of small intracardiac holes with relatively rigid catheters by deflating the balloon and at the same time pulling on the wire and pushing on the catheter.
Disclosures The authors have no conflicts of interest to disclose. References 1. Ruiz CE, Jelnin V, Kronzon I, et al. Clinical outcomes in patients undergoing percutaneous closure of periprosthetic paravalvular leaks. J Am Coll Cardiol 2011;58:2210-7. 2. Confessore P, Fiorilli F, Scappaticci M, et al. Transcatheter closure of mitral paravalvular leak with an arteriovenous wire loop through an aortic mechanical valve prosthesis. Heart Lung Circ 2012;21:850-2. 3. Moreno R, Sanchez Recalde A, et al. Percutaneous closure of mitral paravalvular leaks in patients with aortic valve prostheses. Rev Esp Cardiol 2012;65:768-9. 4. Cruz-Gonzalez I, Rama-Merchan JC, Martin-Moreiras J, RodriguezCollado J, Arribas-Jimenez A. Percutaneous retrograde closure of mitral paravalvular leak in patients with mechanical aortic valve prostheses. Can J Cardiol 2013;29(1531).e15-6. 5. Noble S, Ibrahim R. Transcatheter membranous ventricular septal defect closure through a mechanical aortic prosthesis using the Amplatzer membranous ventricular septal defect occluder. Catheter Cardiovasc Interv 2009;73:167-72.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.01.016.
Stolcova et al. Mitral PVL Closure and Mechanical Aortic Prosthesis
1.e3
Figure 2. (A) The 5F catheter (asterisk) across the leak (large arrows) with the 0.014-inch wire coiling in the left atrium (small arrows). (B) The 5 60 mm balloon stretching the leak (asterisk). (C) “Slide” technique: a partially inflated 4 20 mm balloon (arrow) is used to allow a 7F guiding catheter to enter the left ventricle (LV) from the left atrium. (D) The deployed AMPLATZER Vascular Plug, with its waist (asterisk) stretched and the 2 disks in an asymmetrical fashion to follow the slit-like leak shape.
-
(2014) 1.e1e1.e3 www.onlinecjc.ca
Case Report
Percutaneous Closure of a Small Posterior Mitral Paravalvular Leak in a Patient With Coexistent Monoleaflet Mechanical Aortic Valve Miroslava Stolcova, MD,a Italo Porto, MD, PhD,a,b Francesco Meucci, MD,a Giovanni Squillantini, MD,a and Gennaro Santoro, MDa a b
Interventional Cardiology Unit, Careggi Hospital, Firenze, Italy
Interventional Cardiology Unit, San Donato Hospital, Arezzo, Italy
ABSTRACT
RESUM E
Percutaneous closure of a paravalvular leak is a challenging procedure that often presents with multiple simultaneous hurdles. We report a case of percutaneous retrograde paravalvular leak closure in a patient with a coexistent monoleaflet mechanical aortic valve. The leak was crossed and occluded using a combination of techniques deriving from the coronary and peripheral angioplasty fields.
e d’une fuite paravalvulaire est un acte comLa fermeture percutane s. Nous plexe qui comporte souvent de multiples obstacles simultane e de fuite paravalvulaire par rapportons un cas de fermeture percutane trograde chez un patient ayant une valve aortique me canique voie re e d’un seul feuillet. La fuite a e te franchie et occluse en uticompose lisant une combinaison de techniques relevant du domaine de l’anriphe rique. gioplastie coronarienne et de l’angioplastie pe
Case Presentation A 50-year-old man who had undergone 3 previous valve proceduresda monoleaflet Medtronic Hall prosthesis (Medtronic, Minneapolis, MN) in the aortic position and a Sorin Bicarbon bileaflet valve (Sorin Group, Milan Italy) in the mitral positiond presented with a mitral paraseptal-posterior periprosthetic leak, causing severe hemolysis (Fig. 1 and ; view video online). Transcatheter closure with Video 1 antegrade access was planned. The procedure was performed under transesophageal echocardiographic guidance. During transeptal access, the interatrial septum was dilated with a 4 20 mm coronary balloon (TREK; Abbott Vascular, Abbott Park, IL) to allow the Mullins sheath to cross the fossa. Several antegrade leak engagement attempts with a 0.035-inch 260-cm angled-tip Glidewire (Terumo Medical, Tokyo, Japan) supported by various diagnostic catheters were unsuccessful because of its unfavourable position. Therefore, we switched to a retrograde approach. A 0.014-inch 300-cm guidewire (BALANCE MIDDLEWEIGHT, Abbott Vascular) supported by a 5F 150-cm Radifocus Glidecath (Terumo Medical) was advanced in the left ventricle (LV) across the aortic
; view prosthesis and crossed the leak (Fig. 2A and Video 2 video online). The patient did not experience any hemodynamic deterioration. A 5 60 mm Savvy over-the-wire dilatation catheter (Cordis, Bridgewater, NJ) was advanced through the leak and used to perform a transesophageal echocardiographically guided stop-flow occlusion test. The small tortuous anatomy of the leak ; view video online). was confirmed (Fig. 2B and Video 3 We then created an arteriovenous loop and crossed the leak in an antegrade fashion with a 4F multipurpose catheter, allowing a 0.035-inch AMPLATZ Superstiff wire (Boston Scientific, Natick, MA) to advance into the LV. A 7F JR guiding catheter (Vista Brite Tip; Cordis), which we planned to use to deploy the occluder, was advanced to the LV. Friction, however, was encountered, and a balloon-tracking technique was used, sliding the guiding catheter over the partially inflated 4 20 mm balloon across the leak (Fig. 1C ; view video online). At the end, an and Video 4 AMPLATZER Vascular Plug III (St Jude Medical, St Paul, MN), 10 5 mm, was successfully delivered to completely occlude the leak, with no interference with the valve (Fig. 1D ; view videos online). and Videos 5 and 6
Received for publication December 26, 2013. Accepted January 26, 2014.
Discussion Several hurdles had to be resolved to close the paravalvular leak in our patient. First, the small hole was in a difficult position and was best approached transapically or in a
Corresponding author: Dr Italo Porto, Cardiovascular Department, San Donato Hospital, Via Pietro Nenni, 52100, Arezzo, Italy. E-mail: [email protected] See page 1.e2 for disclosure information.
0828-282X/$ - see front matter Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2014.01.016
1.e2
Canadian Journal of Cardiology Volume - 2014
Figure 1. (A) Transesophageal-derived continuous-wave Doppler tracing (bottom part) of the regurgitant jet caused by the leak. (B) Colour Doppler image of the jet. (C) Location of the leak (red oval) in 3-dimensional surgical view AO, aorta; H, head; LAA, left atrial appendage; P, posterior; PA, pulmonary artery; R, right; RCA, right coronary artery. Modified from Ruiz et al.1 with permission from Elsevier.
retrograde fashion.1 Indeed, it is possible to establish the atrioventricular loop by exteriorizing the wire introduced through the LV apex from the venous access.2 However, we elected to avoid further surgical trauma to this young patient. It is generally accepted that crossing a mechanical valve with a catheter or a wire may result in valve dysfunction. Recently, 3 reports described crossing of bileaflet aortic prostheses: in an antegrade fashion with a 0.035-inch stiff guide wire2,3 and in a retrograde fashion with a 0.035-inch hydrophilic guide wire supported by a 5F catheter.4 A bileaflet valve has even been crossed with a partially opened AMPLATZER septal occluder.5 There is only 1 report3 of a monoleaflet valve crossed in an antegrade fashion with a 0.035-inch wire. No reports exist on retrograde crossing. We used a flexible 5F catheter supporting a 0.014-inch wire and did not observe any hemodynamic deterioration, in contrast to other studies.2-5 Paradoxically, the interaction of a catheter with a monoleaflet valve might be better tolerated than with a bileaflet valve because of the size of the larger orifice in such valves. Other problems of the case were a thick postsurgical interatrial septum and the small dimensions of the paravalvular leak, which were solved by using a coronary balloon to dilate the septum and a peripheral balloon to dilate the leak. Such a technique could be useful in small leaks producing significant compromise. Another important tip is balloontracking to facilitate the crossing of small intracardiac holes with relatively rigid catheters by deflating the balloon and at the same time pulling on the wire and pushing on the catheter.
Disclosures The authors have no conflicts of interest to disclose. References 1. Ruiz CE, Jelnin V, Kronzon I, et al. Clinical outcomes in patients undergoing percutaneous closure of periprosthetic paravalvular leaks. J Am Coll Cardiol 2011;58:2210-7. 2. Confessore P, Fiorilli F, Scappaticci M, et al. Transcatheter closure of mitral paravalvular leak with an arteriovenous wire loop through an aortic mechanical valve prosthesis. Heart Lung Circ 2012;21:850-2. 3. Moreno R, Sanchez Recalde A, et al. Percutaneous closure of mitral paravalvular leaks in patients with aortic valve prostheses. Rev Esp Cardiol 2012;65:768-9. 4. Cruz-Gonzalez I, Rama-Merchan JC, Martin-Moreiras J, RodriguezCollado J, Arribas-Jimenez A. Percutaneous retrograde closure of mitral paravalvular leak in patients with mechanical aortic valve prostheses. Can J Cardiol 2013;29(1531).e15-6. 5. Noble S, Ibrahim R. Transcatheter membranous ventricular septal defect closure through a mechanical aortic prosthesis using the Amplatzer membranous ventricular septal defect occluder. Catheter Cardiovasc Interv 2009;73:167-72.
Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.01.016.
Stolcova et al. Mitral PVL Closure and Mechanical Aortic Prosthesis
1.e3
Figure 2. (A) The 5F catheter (asterisk) across the leak (large arrows) with the 0.014-inch wire coiling in the left atrium (small arrows). (B) The 5 60 mm balloon stretching the leak (asterisk). (C) “Slide” technique: a partially inflated 4 20 mm balloon (arrow) is used to allow a 7F guiding catheter to enter the left ventricle (LV) from the left atrium. (D) The deployed AMPLATZER Vascular Plug, with its waist (asterisk) stretched and the 2 disks in an asymmetrical fashion to follow the slit-like leak shape.
