1. Paravalvular Leak Closure Case Presentation
Samir Kapadia, MD
Professor of Medicine
Director, Cardiac Catheterization Laboratories
Cleveland Clinic
DISCLOSURE : NONE

2. Samir Kapadia, MD
I have no real or apparent conflicts of interest to report.
My presentation will include off label discussions:
Valves

3. Clinical Presentation
79 year old lady
s/p St. Jude #19 AV in 1990
s/p St. Jude # 23 MV in 2004 with CABG (L-AD and SVG to OM)
AF, DDD pacemaker
Severe hemolytic anemia worsening over last 1 year. 30 blood transfusions last year. 8 in last 2 months.
Class III CHF (gets SOB moving from chair to chair)
Question of aortic valve leaflet dysfunction

4. Echocardiogram
TTE
EF – normal (55%)
AV – gradient p/m = 9/5 mm Hg
MV – gradient p/m = 20/8 mm Hg
RVSP = 62 mm Hg
TEE (difficult to pass a probe, esophageal stricture, needed direct visualization with scope to pass the probe)
3+ MR paravalvular

5. TEE

6. Labs Blood cultures (-) LDH = 3618 U/L AST = 166 U/L T Bili 1.9 mg/dL
Haptoglobin <20 mg/dL
BNP = 443 pg/mL

7. Procedure Conscious sedation
Image fusion and planning of the procedure
stiff wire in LV
will not exteriorize
if needed TA puncture

8. Approaches to PVL Closure
Kapadia and Tuzcu, Circ Cardiovasc Interv 2011;4;

9. Procedure Conscious sedation
Image fusion and planning of the procedure
stiff wire in LV
will not exteriorize
if needed TA puncture
Assessment of valves and coronaries
Initial procedure with fluoro and ICE
Pediatric probe

10. Where is the Leak?
Foster GP et al, Ann Thorac Surg 1998; 65:1025–1031

11. Biplane TEE

12. CTA

13. Marking of Area of Interest: Aortic Root

14. Marking of Area of Interest: Leak

15. Marking of Area of Interest: TS Puncture

16. Rotational CT in Cath Lab

17. Fusion

18. Markings on the Fluoro

19. Checking Valve Motion

20. Transseptal Puncture

21. Hemodynamics
Mean LA = 24 mm Hg, V wave = 44 mm Hg

22. Crossing the Defect

23. No Gradient Across AS

24. Advancing the Delivery Sheath

25. Attempt at Deploying Muscular VSD Device

26. TEE with Deployment

27. Interference with Disc

28. Doppler Gradients
Before Deployment
With Deployment

29. Deployment of PDA Device

30. PDA Device

31. Gradients Unchanged
Before
After

32. Functioning Valve After Release

33. LA pressure Before Deployment With Deployment
Mean LA = 24 mm Hg, V wave = 44 mm Hg
Mean LA = 18 mm Hg, V wave = 30 mm Hg

34. F/u Labs Day Prior Post Day 1 LDH = 3618 U/L AST = 166 U/L
T Bili 1.9 mg/dL
Haptoglobin <20 mg/dL
BNP = 443 pg/mL
LDH = 2303 U/L
AST = 80 U/L
T Bili 1.3 mg/dL
Haptoglobin <20 mg/dL
one month Hg = 10.4

35. Thank YOU For ATTENTION