Διαδερµική Σύγκλειση Παραβαλβιδικών Διαφυγών: εµπειρία από ένα κέντρο Σ. Δάρδας 1,2, Ε. Θεοφιλογιαννάκος 1, Ν. Μεζίλης 1, Α. Πίτσης 1, Τ. Κέλπης 1, Δ. Τσικαδέρης 1, Β. Νινιός 1, Π. Δάρδας 1 Κλινική Άγιος Λουκάς, Θεσσαλονίκη και Darriford Hospital, Plymouth, UK
Paravalvular Regurgitation 2-12% of mitral prosthesis 1-5% of aortic valves 60% evident in the first year Common after IE surgery Calcified annulus Redo surgeries Mechanical > Bioprosthetic Ionescu A et al. Heart 2003 Hammermeister K et al. JACC 2000
Symptoms of PVL 1-5% of patients with PVL are symptomatic 93% of symptomatic patients present with CHF (69% NYHA III) 37% with hemolytic anemia 7.5% with infective endocarditis
Prosthetic Valve Regurgitation Recommendations Surgery is recommended for operable patients with mechanical heart valves with intractable hemolysis or HF due to severe prosthetic or paraprosthetic regurgitation Surgery is reasonable for operable patients with severe symptomatic or asymptomatic bioprosthetic regurgitation Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or NYHA class III/IV HF who are at high risk for surgery and have anatomic features suitable for catheter-based therapy when performed in centers with expertise in the procedure COR I IIa IIa LOE B C B
Μέθοδος 8 Ασθενείς (Μέση Ηλικία: 72,00±6,97 έτη) Γυναίκες: 2 (25%) Άντρες: 6 (75%) Ασθενείς µε Παραβαλβιδική Διαφυγή: 7 στη θέση της Μιτροειδούς Το µέσο Logistic EUROSCORE ήταν 28,52± 1 στη θέση της Αορτικής 4,39. Ένδειξη: 6 (75%) αιµόλυση (>2 µεταγγίσεις) 2 (25%) συµπτώµατα ΚΑ (ΝΥΗΑ ΙΙΙ-ΙV) Καθοδήγηση µε 2D/3D TOE Η οδός προσπέλασης: µηριαία φλέβα -
Αποτελέσµατα (I) Σε όλους τους ασθενείς έγινε επιτυχής εµφύτευση συσκευής (Amplatzer Vascular Plug). Η ενδονοσοκοµειακή θνητότητα και η θνητότητα στον 1 µήνα ήταν 0%. Ανάγκη επανεπέµβασης 12,5% Ανάγκη χειρουργείου 12,5% Μικρού βαθµού (+) υπολειµµατική διαφυγή είχαν 2 ασθενείς και µικρού προς µετρίου (+ +) άλλοι 2 ασθενείς. Ένας µόνο ασθενής εµφάνισε ήπια αιµόλυση µετά την εµφύτευση αλλά χωρίς την ανάγκη µετάγγισης αίµατος.
Αποτελέσµατα (II) Στους 2 ασθενείς µε την µετρίου βαθµού υπολειµµατική διαφυγή, προχωρήσαµε σε 2η εµφύτευση συσκευής µε επιτυχή σύγκλειση της παραβαλβιδικής διαφυγής. Οι υπόλοιποι ασθενείς ήταν σε NYHA κλάση I-II. Μία ασθενής εµφάνισε µηριαία αρτηριοφλεβική επικοινωνία που αντιµετωπίσθηκε επιτυχώς µε διαδερµική σύγκλειση.
CASE 1 - History 59 male 1994: subaortic diaphragm resection + Aortic Valve clearance 1995: endocarditis (SBE) Aortic valve replacement (AVR - biologic) 1995: re SBE AVR (metallic) + Mitral Valve Replacement (MVR - metallic) 2010: Mitral Valve paravalvular leak re MVR with bovine pericardial annulus + Aortic aneurysm repair 2014: increasing dyspnoea + hemolysis
2 PARAVALVULAR LEAKS posteromedial (bigger) anterolateral (smaller)
2 PARAVALVULAR LEAKS 3D POSTEROMEDIAL ANTEROLATERAL
Transeptal superior and posterior
transeptal Transeptal sheath through Agilis catheter through
AGILIS CATHETER AGILIS directed posteriorly 5 Fr MP catheter long TERUMO
3D trying to cross
TERUMO THROUGH
SHUTTLE SHEATH through Amplatzer superstiff wire
AVIII DEPLOYMENT
AVIII DEPLOYMENT
AV III final result
Final result moderate residual defect posteromedially inability to approach anterolaterally 2D moderate residual leak 3D incomplete closure
6 months later: increasing dyspnea and re-hemolysis RESIDUAL moderate POSTEROMEDIAL + moderate ANTEROLATERAL DEFECT 2 D 3 D previous device properly aligned anterolateral posteromedial
Posteromedial measurement
Angio RAO trying to cross LAO
AV III through first device
Transapical approach Both defects closed Posteromedial defect 2 nd AVIII 10x5 vascular plug Anterolateral defect AVIII 10x5 vascular plug
FINAL TOE POSTEROMEDIAL no leak ANTEROLATERAL mild residual leak
Final result
Conclusion Patient made full recovery 12 months post procedure is symptom free, NYHA I without hemolysis Paravalvular leak closure is often a complex procedure; both transeptal and transapical approaches are feasible Both approaches can be used complementary 3D TOE final result Anterolateral plug Posteromedial 2 plugs
CASE 2 - HISTORY 42 MALE BICUSPID AS AVR metallic 1995 Redo AVR metallic 2008 (endocarditis)
2010: detached AVR severe paravalvular leak false paraaortic aneurysm aortomitral shunt rupture AMVL OPERATION: AVR BIOLOGIC ST JUDE 23mm Repair AMVL Repair false aneurysm bovine pericardium
2016: hemolysis LDH > 1800 TOE: SEVERE PARAVALVULAR LEAK? 2 HOLES Mild transvalvular leak Moderate LV impairment EF 40% MRI: SEVERE AR REGURGITANT FRACTION 32% PARAVALVULAR AR 90% TRANSVALVULAR AR 10% MODERETE LV IMPAIRMENT
ECHO PRE
ECHO PRE
AORTOGRAM PRE TERUMO THROUGH
MP THROUGH AMPLATZER STIFF THROUGH
ECHO DURING PROCEDURE 2 HOLES
SHUTTLE THROUGH AV III 14X5
AV III 14X5 DEPLOYMENT
AORTOGRAM POST FIRST DEPLOYMENT big hole uncovered
RESIDUAL HOLE AFTER 1 ST CLOSURE
MAINTAIN AV III THROUGH SMALL HOLE AMPLATZER STIFF THROUGH BIG HOLE SHUTTLE THROUGH BIG HOLE
AV III WITHDRAWAL MP THROUGH SMALL HOLE 2 ND AVII 8MM DEVICE SIDE BY SIDE TO 1 ST AVII 14X5MM
2 DEVICES
AV II DELIVERY AV III DELIVERY
FINAL RESULT
PRE POST
FINAL ECHO
Asymptomatic Hb rise LDH 600 POST REPAIR
Percutaneous PARAVALVULAR leak closure IS FEASIBLE Appropriate clinical indication (symptoms, hemolysis) Proper anatomy 2D 3D TOE OBLIGATORY