Chad Kliger

Review of surgical prosthetic paravalvular leaks: diagnosis and catheter-based closure

Paravalvular leak (PVL) is an uncommon yet serious complication associated with surgical prosthetic valve implantation. Paravalvular leak can have significant clinical consequence such as congestive heart failure, haemolytic anaemia, and infective endocarditis. Recently, transcatheter therapy has been applied to the treatment of this disorder with reasonable procedural and clinical success. This review discusses the current state of PVLs, the utilization of multi-modality imaging in their diagnosis and treatment, and the available therapeutic options. Further aim of this review is to examine transcatheter therapy of PVLs including the principles, outcomes, and procedural-related complications.

Transcatheter Reduction of Paravalvular Leaks: A Systematic Review and Meta-analysis

BACKGROUND Significant paravalvular leak (PVL) after surgical valve replacement can result in intractable congestive heart failure and hemolytic anemia. Because repeat surgery is performed in only few patients, transcatheter reduction of PVL is emerging as an alternative option, but its safety and efficacy remain uncertain. In this study we sought to assess whether a successful transcatheter PVL reduction is associated with an improvement in clinical outcomes. METHODS We identified 12 clinical studies that compared successful and failed transcatheter PVL reductions in a total of 362 patients. A Bayesian hierarchical meta-analysis was performed using cardiac mortality as a primary end point. The combined occurrence of improvement in New York Heart Association functional class or hemolytic anemia and the need for repeat surgery, were used as secondary end points. RESULTS A successful transcatheter PVL reduction was associated with a lower cardiac mortality rate (odds ratio [OR], 0.08; 95% credible interval [CrI], 0.01-0.90) and with a superior improvement in functional class or hemolytic anemia, compared with a failed intervention (OR, 9.95; 95% CrI, 2.10-66.73). Fewer repeat surgeries were also observed after successful procedures (OR, 0.08; 95% CrI, 0.01-0.40). CONCLUSIONS A successful transcatheter PVL reduction is associated with reduced all-cause mortality and improved functional class in patients deemed unsuitable for surgical correction.

CT angiography-fluoroscopy fusion imaging for percutaneous transapical access.

OBJECTIVES The aim of this proof-of-principle study is to validate the accuracy of fusion imaging for percutaneous transapical access (TA). BACKGROUND Structural heart disease interventions, including TA, are commonly obtained under fluoroscopic guidance, which lacks important spatial information. Computed tomographic angiography (CTA)-fluoroscopy fusion imaging can provide the 3-dimensional information necessary for improved accuracy in planning and guidance of these interventions. METHODS Twenty consecutive patients scheduled for percutaneous left ventricular puncture and device closure using CTA-fluoroscopy fusion guidance were prospectively recruited. The HeartNavigator software (Philips Healthcare, Best, the Netherlands) was used to landmark the left ventricular epicardium for TA (planned puncture site [PPS]). The PPS landmark was compared with the position of the TA closure device on post-procedure CTA (actual puncture site). The distance between the PPS and actual puncture site was calculated from 2 fixed reference points (left main ostium and mitral prosthesis center) in 3 planes (x, y, and z). The distance from the left anterior descending artery at the same z-plane was also assessed. TA-related complications associated with fusion imaging were recorded. RESULTS The median (interquartile range [IQR]) TA distance difference between the PPS and actual puncture site from the referenced left main ostium and mitral prosthesis center was 5.00 mm (IQR: 1.98 to 12.64 mm) and 3.27 mm (IQR: 1.88 to 11.24 mm) in the x-plane, 4.48 mm (IQR: 1.98 to 13.08 mm) and 4.00 mm (IQR: 1.62 to 11.86 mm) in the y-plane, and 5.57 mm (IQR: 3.89 to 13.62 mm) and 4.96 mm (IQR: 1.92 to 11.76 mm) in the z-plane. The mean TA distance to the left anterior descending artery was 15.5 ± 7.8 mm and 22.7 ± 13.7 mm in the x- and y-planes. No TA-related complications were identified, including evidence of coronary artery laceration. CONCLUSIONS With the use of CTA-fluoroscopy fusion imaging to guide TA, the actual puncture site can be approximated near the PPS. Moreover, fusion imaging can help maintain an adequate access distance from the left anterior descending artery, thereby, potentially reducing TA-related complications.

Successful first-in-man percutaneous transapical-transseptal Melody mitral valve-in-ring implantation after complicated closure of a para-annular ring leak.

AIMS Transcatheter techniques can theoretically be applied to the treatment of para-annular ring (PAR) leaks. Little is known about their potential application and resultant complications in such cases. We describe the first-in-man percutaneous transapical-transseptal Melody valve-in-ring (ViR) implantation after a complication from percutaneous PAR leak closure. METHODS AND RESULTS A 49-year-old woman, at high operative risk, presented with congestive heart failure secondary to severe para-ring/extravalvular regurgitation two months after bypass surgery and mitral ring annuloplasty. Successful percutaneous closure of the leak was performed using an AMPLATZER Vascular Plug IV. One month later, she developed haemolysis with severe PAR regurgitation, through and around the device. After device retrieval and placement of an AMPLATZER Muscular VSD occluder, the patient developed severe intravalvular regurgitation. Completely percutaneous, transseptal delivery of a Melody ViR was performed over a transapical-transseptal, arteriovenous rail. Echocardiography revealed trivial residual regurgitation through the implanted valve with mild transvalvular gradients. CONCLUSIONS Percutaneous closure of mitral PAR leaks after ring annuloplasty in the high-risk patient is feasible (proof-of-concept), particularly when the leak is para-ring/extravalvular. Potential complications include severe intravalvular mitral regurgitation caused by disruption of the mitral apparatus and/or ring deformation during device deployment, which can be successfully treated via percutaneous transapical-transseptal ViR implantation.

Percutaneous Paravalvular Leak Closure

Percutaneous paravalvular leak closure is increasingly being performed as an alternative to reoperation in patients with symptomatic prosthetic paravalvular regurgitation. This article reviews the pathogenesis of paravalvular leaks and percutaneous techniques for closure. Newer multimodality imaging techniques, including 3-dimensional (3D) transesophageal echocardiography and 3D/4D computed tomographic angiography, allow improved preprocedural planning and intraprocedural guidance. Specific techniques can be used for challenging patient anatomy and larger paravalvular leaks. Outcomes from experienced centers show acceptable rates of technical and clinical success, with lower procedural morbidity than reoperation.

Rethinking Percutaneous Paravalvular Leak Closure: Where Do We Go From Here?

Paravalvular leak (PVL) is an uncommon yet serious complications associated with the implantation of surgical prosthetic valves and more recently recognized with transcatheter valves. Renewed interest has developed as relationships have emerged between the degree of paravalvular regurgitation and mortality. 1 Percutaneous closure of PVLs has shown significant promise with contemporary success rates as high as 86%, especially in patients at high risk for surgical repair or replacement. 2,3 Growth in the field of structural heart disease has afforded the adaptation of many technical and procedural advances in an attempt to further improve transcatheter success, while reducing the risk of

Available Transcatheter Aortic Valve Replacement Technology

Transcatheter aortic valve replacement (TAVR) is an alternative and now recommended therapy for patients who meet indications for surgical valve replacement and are high or prohibitive surgical risk. Available TAVR technologies are rapidly emerging to treat this complex patient population. This review discusses the specific valve designs of the transcatheter heart valves currently used, newer generation modifications to overcome limitations of earlier valve designs, and novel imaging modalities, such as computed tomographic angiography-fluoroscopy and echocardiography-fluoroscopy fusion imaging, available for pre-procedural planning and intra-procedural guidance.

Effectiveness of Fluorography Versus Cineangiography at Reducing Radiation Exposure During Diagnostic Coronary Angiography

Coronary angiography is the gold standard for defining obstructive coronary disease. However, radiation exposure remains an unwanted hazard. Patients referred for coronary angiography with abdominal circumference<45 inches and glomerular filtration rate>60 ml/min were randomized to the fluorography (n=25) or cineangiography (n=25) group. Patients in the fluorography group underwent coronary angiography using retrospectively stored fluorography with repeat injection under cineangiography only when needed for better resolution per operators discretion. Patients in the cineangiography group underwent coronary angiography using routine cineangiography. The primary end point was patient radiation exposure measured by radiochromic film. Secondary end points included the radiation output measurement of kerma-area product and air kerma at the interventional reference point (Ka,r) and operator radiation exposure measured by a dosimeter. Patient radiation exposure (158.2 mGy [76.5 to 210.2] vs 272.5 mGy [163.3 to 314.0], p=0.001), kerma-area product (1,323 μGy·m2 [826 to 1,765] vs 3,451 μGy·m2 [2,464 to 4,818], p<0.001), and Ka,r (175 mGy [112 to 252] vs 558 mGy [313 to 621], p<0.001) were significantly lower in the fluorography compared with cineangiography group (42%, 62%, and 69% relative reduction, respectively). Operator radiation exposure trended in the same direction, although statistically nonsignificant (fluorography 2.35 μGy [1.24 to 6.30] vs cineangiography 5.03 μGy [2.48 to 7.80], p=0.059). In conclusion, the use of fluorography in a select group of patients during coronary angiography, with repeat injection under cineangiography only when needed, was efficacious at reducing patient radiation exposure.

Direct percutaneous transaortic approach for treatment of aortic pseudoaneurysms

Aortic pseudoaneurysms (APAs) can develop months or years after aortic and cardiac surgery. If not treated appropriately, APAs can lead to fatal complications and ultimately death. We describe a case of a 61-year old patient with a diagnosed large pseudoaneurysm 5 years after his aortic valve surgery, who was treated with a novel transcatheter direct transaortic approach. The patient had dilated cardiomyopathy with an APA adjacent to the lower sternal plate. An Amplatzer septal occlusion device followed by coils was delivered transcutaneously through the APA to close its neck and fill the false aneurysm, respectively. Triple fusion multimodality imaging was used to guide the placement of the occlusion devices. The merging of computed tomography (CT) and echocardiography with real-time fluoroscopy was fundamental in procedural planning and guidance. Post-procedural transoesophageal echocardiogram (TOE) and CT angiography showed complete exclusion of the APA. A direct transaortic approach is a valid option for closure of an APA if the surgical risk is prohibitive, and the use of triple fusion technology is an essential tool in the hands of interventionalists and surgeons for preoperative planning and conduction of these procedures.

Novel approach for the percutaneous treatment of left ventricular pseudoaneurysms

Left ventricular pseudoaneurysm (LVPA) is a rare yet serious complication that may follow cardiac surgery, myocardial infarction, trauma, or infection. If left untreated, reported rates of rupture and sudden cardiac death are high. Although surgical intervention has traditionally been the standard treatment for LVPA, percutaneous closure is now an attractive alternative in the high‐risk patient. We report a case of a successful percutaneous LVPA closure using direct chest wall entry into the pseudoaneurysm. This novel approach can be useful when access to the LVPA is a challenge, especially in the setting of small ostial size, dense left ventricular trabeculations, angulated serpiginous tract, and presence of mechanical prostheses.