Prosthetic Mitral Perivalvular Defect Occlusion With Multiple Amplatzer Devices Using 3D Transesophageal Echocardiography and Fluoroscopic Guidance Michael Essandoh, MD,* Michelle Humeidan, MD, PhD,* Karina Castellon-Larios, MD,* Barry George, MD, FACC, FSCAI,† Alix Zuleta-Alarcon, MD,* and Emile G. Daoud, MD, FACC†
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ERIVALVULAR MITRAL REGURGITATION IS a serious complication associated with mitral valve replacement surgery. The presence of moderate-to-severe perivalvular leak (PVL) should prompt urgent repair to reduce the risk of associated complications, such as hemolytic anemia and left ventricular remodeling. Historically, PVLs have been corrected with redo mitral valve replacement, which can be associated with a 6% to 22% mortality rate, especially in high-risk patients.1,2 Minimally invasive approaches to perivalvular defect occlusion should, therefore, be considered in high-risk patients to improve survival outcomes. The authors present a case highlighting the value of 3D transesophageal echocardiography (TEE) during minimally invasive PVL repair with Amplatzer II devices. CASE REPORT
A 62-year-old male with history of preserved left ventricular ejection fraction, coronary artery disease and mitral regurgitation underwent triple-vessel coronary artery bypass graft surgery and mitral valve repair in 2011; however, because of progressive and severe mitral insufficiency, mitral valve replacement eventually was performed 1 year later. Over the following year, the mitral valve apparatus developed 2 areas of severe PVL. The first PVL was located along the posterolateral commissure and the second was located at the posteromedial commissure (Fig 1, Video clip 1). Because the patient had multiple comorbidities (high body mass index of 35, type II diabetes mellitus, chronic stage III kidney disease, New York Heart Association class III diastolic heart failure, systemic hypertension, obstructive sleep apnea, and hemolytic anemia secondary to the PVL), as well as severe mitral annular calcification that prohibited availability of adequate anatomic targets to secure a new valve, he was deemed a poor candidate for a third mitral valve surgery. An alternative approach to managing the PVLs was required. After consultation with interventional cardiology and anesthesia, it was decided to proceed with closure of the PVLs using Amplatzer II septal occluder (ASO) devices via left ventricular transapical access under real-time (RT) 3D TEE (X7-2t transducer; Philips Healthcare, Andover, MA) and fluoroscopic guidance. This technique was considered feasible after assessment of the PVLs with a preoperative TEE. The patient was taken to the hybrid operating room, a left radial arterial line was placed, and general anesthesia was induced with successful intubation. A right internal jugular central venous catheter was placed for vascular access and central venous pressure monitoring. A thoracotomy was performed at the level of the left fifth intercostal space. The left ventricular apex was targeted for needle ventriculotomy followed by guidewire advancement and placement of an 18French Gore DrySeal sheath. After heparinization to achieve an
activated clotting time 4300 seconds, a guidewire was inserted from the left ventricle into the left atrium through the posteromedial defect. However, RT 3D TEE demonstrated that the initial positioning of the guidewire was incorrect, and repositioning was directed by TEE imaging. (Figs 2 and 3, Video clips 2 and 3). In addition to RT 3D TEE, the sizing of the posteromedial PVL defect was assessed by use of progressively larger inflatable sizing balloons. With the guidance of 3D en face view of the mitral valve, a 4-mm then an 8-mm occlusive sizing balloon was used to determine the diameter of the defect, which measured 5.0 to 5.5 mm. The complete elimination of the regurgitation by the 8-mm sizing balloon meant an ASO up to 3 mm larger than the 8-mm balloon adequately would occlude the PVL. A 10-mm ASO subsequently was deployed under fluoroscopy and RT 3D TEE visualization to occlude the posteromedial leak (Figs 4, 5, and 6; Video clips 4, 5, and 6); 2D color-flow Doppler (CFD) imaging demonstrated significant reduction of the PVL and improved transvalvular flow. The next step was to address the posterolateral defect. This PVL measured 5.0 to 5.5 mm in diameter and 20 mm in length by RT 3D en face view of the mitral valve. ASO devices measuring 8 mm and 14 mm were deployed simultaneously over guidewires traversing the posterolateral defect to occlude the crescent-shaped PVL (Figs 7, 8, and 9; Video clips 7, 8, and 9). RT 3D TEE confirmed appropriate placement and markedly decreased perivalvular flow. The patient remained hemodynamically stable during deployment, despite experiencing occasional ventricular ectopic beats. The ventriculotomy and thoracotomy then were closed in standard fashion following the removal of the guidewires and the ventricular Gore DrySeal sheath. Postprocedure TEE revealed well-seated ASO devices with minimal residual PVL, as well as normal mechanical valve leaflet mobility with normal transvalvular gradients (Fig 10, Video clip 10). The patient tolerated the procedure well and was transported to the intensive care unit where he was extubated successfully a few hours later. He was discharged
From the *Department of Anesthesiology, and †Department of Internal Medicine, Division of Cardiovascular Medicine, Wexner Medical Center, Ohio State University, Columbus, Ohio. Address reprint requests to Michael Essandoh, MD, Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesiology, The Ohio State University, Wexner Medical Center, Doan Hall N 411, 410 W 10th Ave., Columbus, OH 43210. E-mail: michael.essandoh @osumc.edu © 2015 Elsevier Inc. All rights reserved. 1053-0770/2601-0001$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.10.001 Key Words: mitral valve repair, Amplatzer device, real-time 3D transesophageal echocardiography, perivalvular leak
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 4 (August), 2015: pp 1029–1032
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Fig 1. Three-dimensional transesophageal echocardiography en face view of the mitral valve color-flow Doppler showing the two areas of perivalvular leak in the posterolateral and posteromedial regions.
Fig 4. Three-dimensional transesophageal echocardiography en face view of the mitral valve showing appropriately positioned guidewire sheath prior to deployment of the Amplatzer device.
Fig 2. Three-dimensional transesophageal echocardiography en face view of the mitral valve showing malpositioning of the guidewire.
Fig 5. Multipurpose catheter (5-French) with Amplatzer occluder device located in the smaller perivalvular leak. Flowered out (arrow) distal part of Amplatzer device readily seen. Confirmed position with real time 3D-TEE.
Fig 3. Two-dimensional transesophageal echocardiography midesophageal four-chamber color-flow Doppler showing appropriately placed guidewire through the perivalvular defect.
Fig 6. Amplatzer occluder device in place. Small posteromedial perivalvular leak sealed (arrow) and confirmed by 2D and 3D TEE color-flow Doppler.
PROSTHETIC MITRAL PERIVALVULAR DEFECT OCCLUSION
Fig 7. Mitral valve en face. Guidewire in place across outside of posterolateral perivalvular leak; 18-F Gore Dry Seal sheath and 6F JR4 diagnostic catheter (arrow) coming through apex of the left ventricle. RT 3D TEE mandatory to confirm appropriate position of the wire on outside of sewing ring. Two Amplatzer occluder devices were placed simultaneously through the large sheath to repair this larger posterolateral PVL.
home a week later and remained on warfarin for anticoagulation. At 7 months postprocedure, TEE demonstrated normal biventricular systolic function, well-seated occlusion devices, normal mobility of the mechanical valve leaflets, and trace mitral perivalvular regurgitation. DISCUSSION
Mitral PVLs are considered a serious complication of mitral valve replacement and occur with an incidence of 1% to 12%.1 These patients often present with symptoms of congestive heart failure, arrhythmias, acute kidney injury, endocarditis, and hemolytic anemia.3 Management of PVL by surgical reintervention is technically challenging and is associated with a mortality rate of 6% to 22%.1,2 Although percutaneous devices offer an alternative treatment option for high-risk patients for whom surgery is not an option, deployment of these devices can result in important complications.4 Recently, Kennedy
Fig 8. Amplatzer occluder devices being placed into larger posterolateral PVL, guided with real-time 3D echocardiography.
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Fig 9. Three-dimensional transesophageal echocardiography en face view of the mitral valve showing appropriately placed Amplatzer devices.
et al2 reported a case in which the use of an Amplatzer device was complicated by symptomatic mitral stenosis. Two additional cases were reported in which multiple devices were unsuccessful in closing a mitral PVL.5,6 These reports demonstrated that ASO devices can be associated with incomplete PVL closure and significant complications. To minimize percutaneous device malpositioning and to enhance PVL occlusion with ASO, this case report is the first to demonstrate the advantages of RT 3D TEE to not only measure defect size and location, but also to help address important intraprocedural parameters. Real-time 3D TEE detected incorrect placement of the ASO guidewire and was essential to direct proper wire redeployment. Accurate PVL defect sizing, which is of utmost importance to ASO size selection, was achieved with RT 3D TEE guidance. Traditionally, PVL defect sizing has been achieved with fluoroscopic and 2D TEE guidance using a balloon-sizing method. ASO sizing, up to 3-mm larger than the balloon occlusive diameter, is inserted to occlude the PVL.7 The main
Fig 10. Two-dimensional transesophageal echocardiography midesophageal 4-chamber color-flow Doppler image showing repair of the two areas of perivalvular leak.
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ESSANDOH ET AL
limitation of this technique is the possibility of PVL defect enlargement during balloon inflation, due to the inability to obtain an en face view of the mitral valve. In the case described, inflation of the balloon under RT 3D TEE CFD imaging, enabled accurate sizing of the defect and appropriate ASO selection without any complications. Also, because 3D TEE provides complete simultaneous assessment of mitral valve leaflet function and CFD, these imaging techniques allow for immediate evaluation of any persistent PVL after placement of the ASO and evaluation of valvular leaflet mobility.1,5–9
enlargement, arrhythmias, left ventricular dysfunction, and hemolytic anemia, every effort should be made to correct a PVL. Surgical intervention, however, is not always feasible. This case report highlights the importance of RT 3D TEE imaging for measurement of PVL sizing, assessment and confirmation of ASO deployment, and diagnosing intraoperative complications, such as valvular leaflet dysfunction. The authors believe this technique would help decrease the incidence of PVL recurrence from ASO instability attributable to PVL defect-ASO mismatch.
CONCLUSION
APPENDIX A. SUPPORTING INFORMATION
Because moderate-to-severe mitral PVL causes significant congestive symptoms in association with left atrial
Supplementary data associated with this article can be found in the online version at doi:10.1053/j.jvca.2014.10.001.
REFERENCES 1. Smith CR, Stamou SC, Merhi WM, et al: Repair of paravalvular prosthetic mitral valve leaks with septal occluder devices in severely high-risk patients: a word of caution. Interact Cardiovasc Thorac Surg 15:544-546, 2012 2. Kennedy JL, Mery CM, Kern JA, et al: Mitral stenosis caused by an amplatzer occluder device used to treat a paravalvular leak. Ann Thorac Surg 93:2058-2060, 2012 3. Sciegata A, Álvarez JA, Deketele F, et al: [Percutaneous closure of a mitral paraprosthetic leak with an Amplatzers device]. Medicina (B Aires) 72:431-434, 2012 4. Hourihan M, Perry SB, Mandell VS, et al: Transcatheter umbrella closure of valvular and paravalvular leaks. J Am Coll Cardiol 20: 1371-1377, 1992 5. Mandegar MH, Roshanali F: Prosthetic valve malfunction after Amplatzer closure of paravalvular leak. Ann Thorac Surg 91:614, 2011
6. Merin O, Bitran D, Fink D, et al: Mechanical valve obstruction caused by an occlusion device. J Thorac Cardiovasc Surg 133: 806-807, 2007 7. Hajizeinali A, Sadeghian H, Rezvanfard M, et al: A comparison between size of the occluder device and two-dimensional transoesophageal echocardiographic sizing of the ostium secundum atrial septal defect. Cardiovasc J Afr 24:161-164, 2013 8. Biner S, Rafique AM, Kar S, et al: Live three-dimensional transesophageal echocardiography-guided transcatheter closure of a mitral paraprosthetic leak by Amplatzer occluder. J Am Soc Echocardiogr 21:1282.e7-e9, 2008 9. Hoffmann R, Kaestner W, Altiok E: Closure of a paravalvular leak with real-time three-dimensional transesophageal echocardiography for accurate sizing and guiding. J Invasive Cardiol 25: E210-E211, 2013
P
ERIVALVULAR MITRAL REGURGITATION IS a serious complication associated with mitral valve replacement surgery. The presence of moderate-to-severe perivalvular leak (PVL) should prompt urgent repair to reduce the risk of associated complications, such as hemolytic anemia and left ventricular remodeling. Historically, PVLs have been corrected with redo mitral valve replacement, which can be associated with a 6% to 22% mortality rate, especially in high-risk patients.1,2 Minimally invasive approaches to perivalvular defect occlusion should, therefore, be considered in high-risk patients to improve survival outcomes. The authors present a case highlighting the value of 3D transesophageal echocardiography (TEE) during minimally invasive PVL repair with Amplatzer II devices. CASE REPORT
A 62-year-old male with history of preserved left ventricular ejection fraction, coronary artery disease and mitral regurgitation underwent triple-vessel coronary artery bypass graft surgery and mitral valve repair in 2011; however, because of progressive and severe mitral insufficiency, mitral valve replacement eventually was performed 1 year later. Over the following year, the mitral valve apparatus developed 2 areas of severe PVL. The first PVL was located along the posterolateral commissure and the second was located at the posteromedial commissure (Fig 1, Video clip 1). Because the patient had multiple comorbidities (high body mass index of 35, type II diabetes mellitus, chronic stage III kidney disease, New York Heart Association class III diastolic heart failure, systemic hypertension, obstructive sleep apnea, and hemolytic anemia secondary to the PVL), as well as severe mitral annular calcification that prohibited availability of adequate anatomic targets to secure a new valve, he was deemed a poor candidate for a third mitral valve surgery. An alternative approach to managing the PVLs was required. After consultation with interventional cardiology and anesthesia, it was decided to proceed with closure of the PVLs using Amplatzer II septal occluder (ASO) devices via left ventricular transapical access under real-time (RT) 3D TEE (X7-2t transducer; Philips Healthcare, Andover, MA) and fluoroscopic guidance. This technique was considered feasible after assessment of the PVLs with a preoperative TEE. The patient was taken to the hybrid operating room, a left radial arterial line was placed, and general anesthesia was induced with successful intubation. A right internal jugular central venous catheter was placed for vascular access and central venous pressure monitoring. A thoracotomy was performed at the level of the left fifth intercostal space. The left ventricular apex was targeted for needle ventriculotomy followed by guidewire advancement and placement of an 18French Gore DrySeal sheath. After heparinization to achieve an
activated clotting time 4300 seconds, a guidewire was inserted from the left ventricle into the left atrium through the posteromedial defect. However, RT 3D TEE demonstrated that the initial positioning of the guidewire was incorrect, and repositioning was directed by TEE imaging. (Figs 2 and 3, Video clips 2 and 3). In addition to RT 3D TEE, the sizing of the posteromedial PVL defect was assessed by use of progressively larger inflatable sizing balloons. With the guidance of 3D en face view of the mitral valve, a 4-mm then an 8-mm occlusive sizing balloon was used to determine the diameter of the defect, which measured 5.0 to 5.5 mm. The complete elimination of the regurgitation by the 8-mm sizing balloon meant an ASO up to 3 mm larger than the 8-mm balloon adequately would occlude the PVL. A 10-mm ASO subsequently was deployed under fluoroscopy and RT 3D TEE visualization to occlude the posteromedial leak (Figs 4, 5, and 6; Video clips 4, 5, and 6); 2D color-flow Doppler (CFD) imaging demonstrated significant reduction of the PVL and improved transvalvular flow. The next step was to address the posterolateral defect. This PVL measured 5.0 to 5.5 mm in diameter and 20 mm in length by RT 3D en face view of the mitral valve. ASO devices measuring 8 mm and 14 mm were deployed simultaneously over guidewires traversing the posterolateral defect to occlude the crescent-shaped PVL (Figs 7, 8, and 9; Video clips 7, 8, and 9). RT 3D TEE confirmed appropriate placement and markedly decreased perivalvular flow. The patient remained hemodynamically stable during deployment, despite experiencing occasional ventricular ectopic beats. The ventriculotomy and thoracotomy then were closed in standard fashion following the removal of the guidewires and the ventricular Gore DrySeal sheath. Postprocedure TEE revealed well-seated ASO devices with minimal residual PVL, as well as normal mechanical valve leaflet mobility with normal transvalvular gradients (Fig 10, Video clip 10). The patient tolerated the procedure well and was transported to the intensive care unit where he was extubated successfully a few hours later. He was discharged
From the *Department of Anesthesiology, and †Department of Internal Medicine, Division of Cardiovascular Medicine, Wexner Medical Center, Ohio State University, Columbus, Ohio. Address reprint requests to Michael Essandoh, MD, Department of Anesthesiology, Division of Cardiothoracic and Vascular Anesthesiology, The Ohio State University, Wexner Medical Center, Doan Hall N 411, 410 W 10th Ave., Columbus, OH 43210. E-mail: michael.essandoh @osumc.edu © 2015 Elsevier Inc. All rights reserved. 1053-0770/2601-0001$36.00/0 http://dx.doi.org/10.1053/j.jvca.2014.10.001 Key Words: mitral valve repair, Amplatzer device, real-time 3D transesophageal echocardiography, perivalvular leak
Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 4 (August), 2015: pp 1029–1032
1029
1030
ESSANDOH ET AL
Fig 1. Three-dimensional transesophageal echocardiography en face view of the mitral valve color-flow Doppler showing the two areas of perivalvular leak in the posterolateral and posteromedial regions.
Fig 4. Three-dimensional transesophageal echocardiography en face view of the mitral valve showing appropriately positioned guidewire sheath prior to deployment of the Amplatzer device.
Fig 2. Three-dimensional transesophageal echocardiography en face view of the mitral valve showing malpositioning of the guidewire.
Fig 5. Multipurpose catheter (5-French) with Amplatzer occluder device located in the smaller perivalvular leak. Flowered out (arrow) distal part of Amplatzer device readily seen. Confirmed position with real time 3D-TEE.
Fig 3. Two-dimensional transesophageal echocardiography midesophageal four-chamber color-flow Doppler showing appropriately placed guidewire through the perivalvular defect.
Fig 6. Amplatzer occluder device in place. Small posteromedial perivalvular leak sealed (arrow) and confirmed by 2D and 3D TEE color-flow Doppler.
PROSTHETIC MITRAL PERIVALVULAR DEFECT OCCLUSION
Fig 7. Mitral valve en face. Guidewire in place across outside of posterolateral perivalvular leak; 18-F Gore Dry Seal sheath and 6F JR4 diagnostic catheter (arrow) coming through apex of the left ventricle. RT 3D TEE mandatory to confirm appropriate position of the wire on outside of sewing ring. Two Amplatzer occluder devices were placed simultaneously through the large sheath to repair this larger posterolateral PVL.
home a week later and remained on warfarin for anticoagulation. At 7 months postprocedure, TEE demonstrated normal biventricular systolic function, well-seated occlusion devices, normal mobility of the mechanical valve leaflets, and trace mitral perivalvular regurgitation. DISCUSSION
Mitral PVLs are considered a serious complication of mitral valve replacement and occur with an incidence of 1% to 12%.1 These patients often present with symptoms of congestive heart failure, arrhythmias, acute kidney injury, endocarditis, and hemolytic anemia.3 Management of PVL by surgical reintervention is technically challenging and is associated with a mortality rate of 6% to 22%.1,2 Although percutaneous devices offer an alternative treatment option for high-risk patients for whom surgery is not an option, deployment of these devices can result in important complications.4 Recently, Kennedy
Fig 8. Amplatzer occluder devices being placed into larger posterolateral PVL, guided with real-time 3D echocardiography.
1031
Fig 9. Three-dimensional transesophageal echocardiography en face view of the mitral valve showing appropriately placed Amplatzer devices.
et al2 reported a case in which the use of an Amplatzer device was complicated by symptomatic mitral stenosis. Two additional cases were reported in which multiple devices were unsuccessful in closing a mitral PVL.5,6 These reports demonstrated that ASO devices can be associated with incomplete PVL closure and significant complications. To minimize percutaneous device malpositioning and to enhance PVL occlusion with ASO, this case report is the first to demonstrate the advantages of RT 3D TEE to not only measure defect size and location, but also to help address important intraprocedural parameters. Real-time 3D TEE detected incorrect placement of the ASO guidewire and was essential to direct proper wire redeployment. Accurate PVL defect sizing, which is of utmost importance to ASO size selection, was achieved with RT 3D TEE guidance. Traditionally, PVL defect sizing has been achieved with fluoroscopic and 2D TEE guidance using a balloon-sizing method. ASO sizing, up to 3-mm larger than the balloon occlusive diameter, is inserted to occlude the PVL.7 The main
Fig 10. Two-dimensional transesophageal echocardiography midesophageal 4-chamber color-flow Doppler image showing repair of the two areas of perivalvular leak.
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ESSANDOH ET AL
limitation of this technique is the possibility of PVL defect enlargement during balloon inflation, due to the inability to obtain an en face view of the mitral valve. In the case described, inflation of the balloon under RT 3D TEE CFD imaging, enabled accurate sizing of the defect and appropriate ASO selection without any complications. Also, because 3D TEE provides complete simultaneous assessment of mitral valve leaflet function and CFD, these imaging techniques allow for immediate evaluation of any persistent PVL after placement of the ASO and evaluation of valvular leaflet mobility.1,5–9
enlargement, arrhythmias, left ventricular dysfunction, and hemolytic anemia, every effort should be made to correct a PVL. Surgical intervention, however, is not always feasible. This case report highlights the importance of RT 3D TEE imaging for measurement of PVL sizing, assessment and confirmation of ASO deployment, and diagnosing intraoperative complications, such as valvular leaflet dysfunction. The authors believe this technique would help decrease the incidence of PVL recurrence from ASO instability attributable to PVL defect-ASO mismatch.
CONCLUSION
APPENDIX A. SUPPORTING INFORMATION
Because moderate-to-severe mitral PVL causes significant congestive symptoms in association with left atrial
Supplementary data associated with this article can be found in the online version at doi:10.1053/j.jvca.2014.10.001.
REFERENCES 1. Smith CR, Stamou SC, Merhi WM, et al: Repair of paravalvular prosthetic mitral valve leaks with septal occluder devices in severely high-risk patients: a word of caution. Interact Cardiovasc Thorac Surg 15:544-546, 2012 2. Kennedy JL, Mery CM, Kern JA, et al: Mitral stenosis caused by an amplatzer occluder device used to treat a paravalvular leak. Ann Thorac Surg 93:2058-2060, 2012 3. Sciegata A, Álvarez JA, Deketele F, et al: [Percutaneous closure of a mitral paraprosthetic leak with an Amplatzers device]. Medicina (B Aires) 72:431-434, 2012 4. Hourihan M, Perry SB, Mandell VS, et al: Transcatheter umbrella closure of valvular and paravalvular leaks. J Am Coll Cardiol 20: 1371-1377, 1992 5. Mandegar MH, Roshanali F: Prosthetic valve malfunction after Amplatzer closure of paravalvular leak. Ann Thorac Surg 91:614, 2011
6. Merin O, Bitran D, Fink D, et al: Mechanical valve obstruction caused by an occlusion device. J Thorac Cardiovasc Surg 133: 806-807, 2007 7. Hajizeinali A, Sadeghian H, Rezvanfard M, et al: A comparison between size of the occluder device and two-dimensional transoesophageal echocardiographic sizing of the ostium secundum atrial septal defect. Cardiovasc J Afr 24:161-164, 2013 8. Biner S, Rafique AM, Kar S, et al: Live three-dimensional transesophageal echocardiography-guided transcatheter closure of a mitral paraprosthetic leak by Amplatzer occluder. J Am Soc Echocardiogr 21:1282.e7-e9, 2008 9. Hoffmann R, Kaestner W, Altiok E: Closure of a paravalvular leak with real-time three-dimensional transesophageal echocardiography for accurate sizing and guiding. J Invasive Cardiol 25: E210-E211, 2013
