Closure of Perprosthetic Aortic

and Mitral Leaks with Devices

(Options, Techniques, Outcomes and
Future Needed Directions)

EULOGIO GARCIA
Hospital Clínico San Carlos
MADRID
 BACKGROUND
• The incidente of paravalvular leaks is variable
( from 2% to 7% ). It approaches 30% in those
operated because of paravalvular leak.

• Surgical approach has been traditionally

considered the treatment of choice

• In the past years an alternative therapeutic

approach has been sought
 Therapeutic Options

• Medical treatment of hemolysis, CHF or both

• Surgical repair of perivalvular leak #
• Surgical replacement with a new valve #
• Percutaneous repair of perivalvular leak ##

#
Echevarria et al. Eur. Cardio Surg. 1991; 523-26.
##
Kim et al. JACC Interv 2009; 2: 81-90
 TEC HNIQUE S

ortic Leak

iag nos is : Ang iog raphy and

E chocardiog raphy

as cular acces s : Femoral or B rachial

 Aorta

Catheter

Guide Wire
 TE C HNIQUE S

Mitral Leak:
• Diagnosis:
 2D Echocardiography for diagnosis and
location *
 3D Echocardiography for size and shape **
 Pre-procedural planing with rapid
prototyping***

*C ortes et al. Am J C ardiol 2008; 101: 382-6 **M arx et al. C ardiol C lin 2007; 25:
357-65
 Mitral leak
• Right femoral vein and right/ left femoral
artery approach
• Transeptal puncture
• Anterograde or retrograde leak approach
• Amplatzer sheath to LV throught the leak
• TEE procedural guidance
• Amplatzer occluder positioning and release
Mitral Leak
• Transeptal puncture can be difficult and
sometines requires SVC approach
• Leak access: Antegrade or retrograde
• Leak crossing: Terumo wire through IM
(anterior), multipurpose (posterior) or RCA
( medial) catheters in antegrade approach
• Terumo wire through multipurpose catheter in
retrograde approach
Result post procedure
 MITRAL PERIVALVULAR LEAKS

Loosen up your imagination

(Special tricks)

1. Use inflated Swan-Ganz catheter to undo LA

loop and exchange high support wire
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
 2D- 3D TEE Echocardioghraphy

• Define leak anatomy

• Guide leak passage of wire and device

• Assess procedural result

 OUTCOMES

• Surgery

• Percutaneous procedire

• Our own experience

 SURGICAL EXPERIENCE

• 136 Re-interventions (107 because of

paravalvular leak)
• Operative mortality : 6.6%
• Perioperative stroke : 5.1%
• Freedom from repeated paravalvular leak :
63%
• K-M 10-year survival : 30%

Akins et al. J Heart V. Dis 2005; 14: 792-799

 PERCUTANEOUS RESULTS

Published reports : 10 papers , 52 patients

Technical success : 44/52 ( 86% )
Clinical success : 28/52 ( 53%)
 
JACC 1992; 20:1371. CCI: 2005;65:69. JHVD 2007; 16:305. CCI 2000; 49:64. CCI
2001; 54: 234. CCI 2007 ; 69: 708. CCI 2007; 70:815.

Kim et al..JACC, CCV Interventions 2009; 2: 81-90

Kim et al. JACC Interv 2009; 2:81-90
 Personal experience
• Procedures : 127
• Mitral : 103
• Aortic : 21
• Mitro-aortic : 3
• Devices : Duct occluder : 96. VPIII: 31
 AORTIC PARAVALVULAR LEAKS

Results
Procedural success 16/17

Clinical improvement 14/17

Mortality ( > 3mo ) 1/17

Surgery ( > 3 mo ) 2/17

 MITRAL PARAVALVULAR LEAK
RESULTS N= 79
Procedural success 60 /79 (76%)

Mortality( > 3 m ) 5/79 (6%)

Surgery ( > 3m ) 4/79 (5%)

Clinical improvement 55/79 ( 70%)

AMPLATZER® Vascular Plug III
Under review

•Double-lobed, multi-
layer and oval-shaped

•Extended rims for better

apposition in high flow
situations.

•Faster occlusion time

 EXPERIENCE WITH THE NEW
DEVICE VP III

(January – August 2009)

Hospital Clinico San Carlos
Patients = 26, Procedures = 31 Devices =29)
 B AS ELINE
C HAR AC
N=TER
26 IS TIC S
Age 63±11 yrs

Gender 14 male, 12 Female

Leak Location 22 Mitral, 3 Aortic, 1 Aorto mitral

Valve type 24 Mechanical, 3 Biological

 PR OC EDUR AL
C HAR ACN=TER
31 IS TIC S
Vascular Access Femoral 29, Brachial 2

Loop ( A-V, A-A, V-V ) 23 (75%)

Delivery catheter AGA sheath ( 6-7 Fr.): 23

Sheathless GC (6.5Fr): 3
Destination GC ( 7Fr) : 2
Heart Trail ( 6 Fr): GC
Device size 8/4 mm: 19;
6/3 mm : 9;
10/5 mm :1;
12/5 : 1;
14/5: 1
 PR OC E DUR AL R ES ULTS
N= 31
Procedural success 28/31 ( 90 %)

Patient success 26/26 ( 100% )

Device success Complete closure : 17/29 ( 58% ),

Partial closure ( 42%)

Complications : 2 pseudoaneurysms,
1 A-V fistula
 FOLLOW-UP R ES ULTS
N= 26
Death 2 (7%)

Redo- Surgery 0

Clinical improvement 22/26 ( 84%)

Absent or minimal leak (TEE) 20/24 ( 83% )

 FUTURE DIRECTIONS

• Better definition by different imaging

modalities
• More experience with Rapid Prototyping
• Improved lubrication of transporting sheaths
to facilitate passage
• Improve device design
• Validate other options ( TRANSAPICAL
APPROACH )
 CONCLUSIONS

• The new VP III is anatomically and functionally more

adequate device to treat paravalvular leaks
• The treatment of mitral paravalvular leaks is still a
clallanging procedure
• In most cases the retrograde access and an arterio-
venous loop is an easier and faster way to repair mitral
paravalvular leaks
• 3D TEE is of great help to design and guide the procedure
• Percutaneous repair of paravalvular leaks should be in
my opinión the first option of treatment