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• W2069955847 abstract "We have read with great interest the recent article by Jones-Haywood et al1Jones-Haywood M.M. Combs C. Pu M. et al.Percutaneous closure of mitral paravalvular leak.J Cardiothorac Vasc Anesth. 2013; 27: 168-177Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar entitled “Percutaneous Closure of Mitral Paravalvular Leak.” The authors described the percutaneous transcatheter closure of a mitral paravalvular leak (PVL) with two AMPLATZER devices (St. Jude Medical, St. Paul, MN) in 2 stages. The authors discussed the potential complications of percutaneous closure of a mitral PVL with an antegrade approach. Percutaneous transcatheter closure of PVL has emerged as a promising, less-invasive alternative method to surgery. However, this procedure is complex, time-consuming, and not always successful, especially in complicated cases, such as patients with repeated valve replacements, heavy annular calcification, and localized infection. We share our experience with percutaneous closure of a mitral PVL in a complicated case and discuss whether this technique really is helpful, especially in complicated cases. A 34-year-old man with shortness of breath was referred to our hospital for percutaneous closure of a mitral PVL because of high operative risk. He had undergone valve surgery (aortic and mitral valve replacement) in 2006 and a second mitral valve replacement for severe mitral PVL because of infective endocarditis in 2009. In October 2011, he again presented with severe mitral PVL. He had moderate dyspnea (New York Heart Association functional class III). Physical examination revealed orthopnea, tachycardia (108 beats/min), rales in the lower segments of the lungs, and apical 2-3/6 systolic murmur with prosthetic sounds. Laboratory examination revealed severe hemolysis, hemolytic anemia with hemoglobin levels of 9.8 g/dL, and significantly increased lactate dehydrogenase levels (1,080 IU/L). Transthoracic echocardiography and transesophageal echocardiography (TEE) revealed one wide moderate-slope tunnel–type PVL close to the septal side of the prosthetic valve (3 o’clock position) and one small oval PVL on the lateral side (8 o’clock position). The patient was very symptomatic. First, optimal medical treatment for pulmonary congestion was given. The operative risk was very high because of two previous valve operations. The estimated surgical risk was 6 points according to the EuroSCORE (estimated mortality 10.9%-11.5%). A percutaneous closure of the moderate-slope tunnel–type PVL close to the septal side (3 o’clock position) was decided. Informed patient consent was obtained. The procedure was performed under general anesthesia, with three-dimensional TEE guidance. An antegrade technique was obligatory because of aortic valve replacement. The PVL was in a posteromedial position, so an inferoposterior septal puncture (at the fossa ovalis) to facilitate the medial access was done. (If a PVL is in a lateral position, a classic puncture to facilitate lateral access could be better). A transseptal puncture was carried out using the standard technique (Mullins sheath and Brockenbrough needle; Medtronic Inc., Minneapolis, MN). When access to the left atrium had been gained, the dilator was withdrawn, and the tip of the Mullins sheath was directed medially. This movement facilitated access to the PVL posteromedially. After passing the PVL with a straight hydrophilic wire (Terumo; Terumo Co., Somerset, NJ), a 6F multipurpose catheter was inserted into the left ventricle. Subsequently, a Super Stiff Guidewire (Amplatz, Boston Scientific Co., Natick, MA) was advanced into the left ventricle. Finally, a 7F right Judkins guiding catheter was advanced into the left ventricle. Once this setup had been established, the first AMPLATZER Duct Occluder (ADO) II (waist size, 6 mm; length, 6 mm; disk diameter, 12 mm) was released in its entirety and placed correctly. All movements except transseptal puncture were repeated during the deployment of a second ADO II device (waist size, 6 mm; length, 6 mm; disk diameter, 12 mm) (Fig 1A). Two-dimensional and three-dimensional TEE demonstrated that the two ADO devices were placed correctly, the defect was closed gradually, the severe mitral PVL had almost disappeared, and prosthetic valve function was normal without any impingement (Fig 1B and C). Total procedural time was 110 minutes, and fluoroscopy time was 40 minutes. The patient’s symptoms resolved after PVL closure. The patient’s symptoms returned and worsened 2 months later. Two-dimensional TEE revealed that the degree of the PVL regurgitation on the septal side of the prosthetic valve where the ADO II devices were deployed was increased (Fig 2A). Also, the degree of PVL regurgitation on the lateral side of the prosthetic valve (8 o’clock position) was increased. Three-dimensional TEE demonstrated that tearing at both ends of the defect, where the ADO II devices were deployed previously, was increased (Fig 2B). We considered that the previously deployed ADO II devices promoted tearing at both ends of dehiscence while being deployed, further increasing the patient’s symptoms. This time, percutaneous closure was deemed inappropriate, and it was decided to perform surgery so as not to increase the degree of mitral PVL at the defect site or any other location (Fig 3A and B).Fig 3Intraoperative images show extraction of the ADO II device (A) and increased tearing at both ends of the defect (B).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Although percutaneous transcatheter closure of PVLs is a technically feasible and safe treatment modality, the procedure is not always successful. Complex and unfavorable anatomy of PVLs, inadequate imaging techniques, lack of perfect fit of the occluder devices within the leak cavity, and lack of experience of the operator have been defined as potential causes for failure of percutaneous closure of PVLs. The main reason for failure may be related to the complex anatomy of the defect. There were no established cutoff values recommended for closure and no specific anatomic criteria for exclusion. Successful closure is limited by the anatomy of the defects, which tend to be large, irregular, and with multiple perforations. Although most mitral PVLs reported in the literature are rectangular or crescent-shaped, the PVL in our case was a slope-tunnel type. In addition to anatomy of the defect, it is important to know the underlying pathology. In the United States,>60,000 prosthetic valves are implanted surgically annually, and it was reported that paravalvular regurgitation usually is related to tissue fragility, annular calcification, or infection.2Rihal C.S. Sorajja P. Booker J.D. et al.Principles of percutaneous paravalvular leak closure.JACC Cardiovasc Interv. 2012; 5: 121-130Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar Our patient had had two mitral valve replacement operations (second one for infective endocarditis), and tissue fragility might have been the cause of failure. Success of closure of a PVL almost always depends on the defect shape and size rather than commercially available device types. Nonetheless, there is not a perfect fit of the occluder devices within the PVL cavity. Current devices are not designed specifically for percutaneous closure of PVLs. Off-label devices such as ADO I, ADO II, AMPLATZER Vascular Plug (AVP), and AMPLATZER Septal Occluder devices currently are used. These devices are sufficient in cases with favorable anatomy; however, PVLs frequently are crescent-shaped, leading to difficulties with successful closure using a single device, necessitating a relatively large device or multiple devices.3Noble S. Basmadjianb A. Ibrahim R. Transcatheter prosthetic paravalvular leak closure.Cardiovasc Med. 2012; 15: 245-252Google Scholar AVP III may provide greater conformability to a range of crescent-shaped PVLs.4Nietlispach F. Johnson M. Moss R.R. et al.Transcatheter closure of paravalvular defects using a purpose-specific occluder.JACC Cardiovasc Interv. 2010; 3: 759-765Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar However, the successful outcome of the closure of a PVL by a AVP still is not shown convincingly in the literature. Use of an unsuitable device or use of a second device at the same session also may promote tearing at both ends of dehiscence during deployment, further increasing the degree of regurgitation. In conclusion, although percutaneous transcatheter closure of PVLs has been regarded as an alternative therapy to surgery, the procedure is complex, time-consuming, and not always successful, especially in complicated cases. The perfect fit of PVL and occluder devices is still the main challenge of this procedure, and sometimes more than one device must be used, especially in large defects with complex anatomy. Preoperative patient or defect selection is important. Further studies of clinical efficacy and safety of using multiple devices in the era of percutaneous closure of PVLs beyond the acute time period are required." @default.
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• W2069955847 date "2013-08-01" @default.
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• W2069955847 title "Is Percutaneous Closure of Paravalvular Leaks Really Helpful, Especially in Complicated Cases?" @default.
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