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Adult Congenital Heart Disease Basic Teaching Course ACHD Curriculum: Case Lessons in Catheterization Percutaneous Treatment of Paravalvular Leaks Chad.

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Presentation on theme: "Adult Congenital Heart Disease Basic Teaching Course ACHD Curriculum: Case Lessons in Catheterization Percutaneous Treatment of Paravalvular Leaks Chad."— Presentation transcript:

1 Adult Congenital Heart Disease Basic Teaching Course ACHD Curriculum: Case Lessons in Catheterization Percutaneous Treatment of Paravalvular Leaks Chad Kliger, MD, MS Assistan t Professor, Hofstra School of Medicine Vladimir Jelnin, MD Director of Cardiac CT Imaging Laboratory Carlos E. Ruiz, MD, PhD Professor, Hofstra School of Medicine Lenox Hill Hospital North Shore LIJ

2 ISACHD Congenital Heart Disease Basic Course Case Objectives Illustrate a case of symptomatic prosthetic paravalvular regurgitation treated with percutaneous closure Discuss the basic principles, imaging modalities, outcomes, and complications for percutaneous closure Describe transcatheter techniques of closure with a focus on percutaneous transapical access

3 ISACHD Congenital Heart Disease Basic Course Case Summary 48 year old male Mitral regurgitation s/p repair 11/2009 complicated with severe systolic anterior motion/left ventricular outflow tract obstruction S/p bioprosthetic mitral valve replacement 6/2010 Infective endocarditis 7/2011 requiring aortic and redo mitral valve replacements (St Jude Mechanical, aortic #23, mitral #27) Presents with severe congestive heart failure NYHA III and hemolytic anemia requiring blood transfusions every 2-3wks for last 5 months Denies fevers, chills; labs including blood cultures and Gallium/SPECT scan were unremarkable

4 ISACHD Congenital Heart Disease Basic Course Case Summary Physical Exam: BP 116/80, HR 80, RR 12, 98% RA Mild scleral icterus, +JVD 8cm Mechanical S1/S2, 3/6 holosystolic murmur at apex radiating to axilla Decreased breath sounds bilateral bases 1/3 up Trace bilateral lower extremity edema Labs: Hemoglobin 8.3 g/dL, haptoglobin <8 mg/dL, NT proBNP 3193 pg/mL, LDH 40,000 U/l, INR 2.3, total bilirubin 2.2 mg/dL

5 ISACHD Congenital Heart Disease Basic Course Transesophageal Echocardiogram

6 ISACHD Congenital Heart Disease Basic Course Computed Tomographic Angiography 3D/4D

7 ISACHD Congenital Heart Disease Basic Course Percutaneous Transapical Mitral PVL Closure CTA-fluoroscopy fusion imaging (HeartNavigator, Philips) for guidance Simultaneous delivery of AVP II 8mm x2 devices; transapical closure using an AVP II 8mm

8 ISACHD Congenital Heart Disease Basic Course Post-Procedural CTA

9 ISACHD Congenital Heart Disease Basic Course Background PVL(s) result from an incomplete seal between sewing ring and annulus Risk factors for PVL Annular calcification, tissue friability Infection Suturing technique Size and shape of prosthetic implant Surgical valve replacement 2-10% in aortic position, 7-17% in mitral position Transcatheter aortic valve replacement Moderate PVL in 13.5% (Sapien, Edwards) and 19.9% (CoreValve, Medtronic) Gilard et al. NEJM 2012

10 ISACHD Congenital Heart Disease Basic Course Background 80% of surgical PVLs referred for closure are in the mitral position 1-5% of patients with PVL are symptomatic Symptoms: Congestive heart failure (~90% of cases, NYHA ≥3) Hemolysis Combination (CHF+Hemolysis) Aortic: Posterior (non-coronary) cusp is most common, followed by left cusp Mitral: Inter-trigonal (10 to 1o’clock) and posteroseptal (1 to 6o’clock) are most common

11 ISACHD Congenital Heart Disease Basic Course Imaging of PVL Echocardiography: Transthoracic (TTE) and transesophageal (TEE) can determine the spatial characteristics along with prosthetic valve function 3D TEE is superior to 2D TEE, providing improved localization and analysis of shape and size Color Doppler can localize regurgitation and assess severity Computed Tomography: 3D/4D reconstruction using volume rendering techniques With adjustment of opacity and color and applying cut-planes, can provide localization and analysis of shape and size Assists with technical planning for closure

12 ISACHD Congenital Heart Disease Basic Course Transcatheter techniques provide a less-invasive approach to closure compared to surgery Absence of dedicated devices for percutaneous closure Off-label use of Amplatzer family of devices Shapes: oval/round vs. crescentic or indeterminate Serpiginous tracks Technique of: multiple smaller devices, simultaneous or sequential delivery (better conformation to PVL) Devices/Technique Kliger et al. EHJ 2012.

13 ISACHD Congenital Heart Disease Basic Course Access Sites for PVL Closure Order of approach: most to least likely Mitral: retrograde transapical (institution dependent), antegrade transseptal, and retrograde transaortic Aortic: retrograde transaortic, antegrade transapical, and antegrade transseptal Creation of an exteriorized rail: complete control/support Dudiy et al. SHD Interventions. Lippincott 2012. Arterio-venous Veno-ventricular Arterio-ventricular

14 ISACHD Congenital Heart Disease Basic Course Case Series of Percutaneous ClosureAuthorYearPtsPVLsTechnicalSuccessClinicalSuccessHourihan1992333(100%)2(67%) Pate200610107(70%)4(57%) Hein2006212624(92%)14(67%) Shapira2007111311(85%) 6( 54%) Sorajja2007161917(89%)12(75%) Cortes2008272717(63%)10(59%) Garcia-BorbollaFernandez2009885(63%)4(80%) Nietlispach2010555(100%)5(100%) Sorajja 1 2011 11 5 141133(94%)88(77%) Ruiz 2 2011435749(86%)37(89%) AVG 88%59%

15 ISACHD Congenital Heart Disease Basic CourseAuthorComplicationsHourihan Hemolysis + migration (1, 25%) Pate Device dislodgement requiring sx (1, 10%) Persistent hemolysis (2, 20%) Retroperitoneal bleeding (1,10%) Hein Endocarditis (1, 4.7%) Device interference with valve requiring sx (1, 4.7%) Hemolysis requiring sx (2, 9.4%) Cortes Ventricular arrhythmia requiring cardioversion (1, 3.7%) Transient asystole (1, 3.7%) Bleeding events (5, 1.9%) Cerebrovascular events (2, 7.4%) Pericardial effusion (1, 3.7%) Alonso-Briales Residual shunts (3, 37.5%) Residual shunt requiring surgery (1, 12.5%) Garcia-Borbolla Massive stroke/death (1, 12.5%) Sorajja Death (2, 1.6%) Emergency CV sx (1, 0.8%) Hemothorax (4, 3.2%) IC hemorrhage, embolic stroke (3, 3.2%) Vascular complication (1, 0.8%) Ruiz(Non-Transapical) Acute embolization, (1, 2.3%) Wire entrapment (1, 2.3%) Iliac dissection (1, 2.3%) Summary of Complications Summary: 1.4-2% death, 0.7-2% emergent cardiac surgery, 0.7-2% access- related complications, 2.5% hemothorax (transapical), 0.7-4% device-related complications, 3.5-5% interference with prosthetic valve

16 ISACHD Congenital Heart Disease Basic Course Case Follow-up: 6mo Patient at NYHA I, able to ride bike 6 miles without limitation No further transfusion requirements Labs: Hemoglobin 11.4 g/dL, NT proBNP 1466 pg/mL, LDH 594 U/l, INR 2.4, total bilirubin 0.8 mg/dL

17 ISACHD Congenital Heart Disease Basic Course Case Follow-up: 6mo TTE

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