Author + information
- Received August 13, 2012
- Accepted August 31, 2012
- Published online February 1, 2013.
- ↵⁎Reprint requests and correspondence:
Dr. Matthew J. Price, Scripps Clinic, 10666 North Torrey Pines Road, Maildrop S1056, La Jolla, California 92037
Paravalvular leak (PVL) occurs more frequently after transcatheter aortic valve replacement (TAVR) than after surgical replacement (1). PVL may be due to prosthesis underexpansion, undersizing, impingement of calcium nodules interfering with stent expansion, or incorrect positioning so the valve skirt is not completely apposed to the aortic annulus. Even mild PVL is associated with increased late mortality (1). Clinical experience with percutaneous closure of PVL after TAVR is limited, but this could be a reasonable strategy in these high-risk patients. Prior devices used for percutaneous closure have required delivery guide sheaths from 5- to 8-F (2). Two patients with severe aortic stenosis and New York Heart Association class IV symptoms underwent TAVR with a 26-mm Sapien valve (Edwards Lifesciences, Irvine, California) complicated by moderate-to-severe aortic insufficiency (AI) and acute heart failure. In both cases, the PVL was closed successfully with an Amplatzer Vascular Plug (AVP)-4 (St. Jude, St. Paul, Minnesota) delivered through a 4- or 5-F diagnostic catheter, with subsequent resolution of symptoms (Figs. 1 and 2)⇓.
Figure 1 shows the percutaneous closure of paravalvular leak after Sapien valve-in-valve TAVR. An 86-year-old man underwent TAVR with a 26-mm Sapien valve, complicated by central and paravalvular AI; after implantation of a second valve, moderate-to-severe paravalvular AI persisted. The patient quickly decompensated, presenting with multiorgan failure. A 4-F diagnostic Multipurpose (MP) catheter was advanced across the tract over a stiff angled glidewire; a 6-mm AVP-4 was then advanced and deployed, resulting in substantial reduction of AI and rapid clinical recovery. TEE long-axis (Fig. 1A) and short-axis views (Fig. 1B) demonstrate moderate-to-severe AI. Right anterior oblique–cranial projection confirms the 4-F MP catheter has been advanced outside the struts of the Sapien valves (Fig. 1C). A 6-mm AVP-4 is advanced (Fig. 1D) and deployed (arrow) (Fig. 1E), resulting in substantial reduction of AI by TEE in the long-axis (Fig. 1F) and short axis (Fig. 1G) views.
Figure 2 shows the percutaneous closure of paravalvular leak after Sapien TAVR. A 90-year-old man underwent TAVR with a 26-mm Sapien valve, complicated by moderate-to-severe paravalvular AI, leading to decompensated heart failure. Long-axis (Fig. 2A) and short-axis (Fig. 2B) views of the aortic valve, showing moderate-to-severe AI following TAVR. A 5-F MP diagnostic catheter advanced over a glidewire into the left ventricular chamber (Fig. 2C). An 8-mm AVP-4 was deployed and released within the paravalvular track (arrows) (Fig. 2D). Long-axis (Fig. 2E) and short-axis (Fig. 2F) views of the aortic valve after occluder placement demonstrates significant reduction in AI. The patient had a rapid clinical recovery.
These cases illustrate the morbidity associated with PVL after TAVR and demonstrate the feasibility of percutaneous closure using occluders that can be delivered through low-profile catheters. These low-profile systems greatly improve the ability to close PVL after TAVR. Whether this approach improves survival requires further study.
Dr. Feldman has received grants and consulting fees from Abbott, Boston Scientific, and Edwards. Dr. Price has received consulting fees from St. Jude. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 13, 2012.
- Accepted August 31, 2012.
- American College of Cardiology Foundation