Journal of the New Zealand Medical Association, 05-September-2008, Vol 121 No 1281
Percutaneous transcatheter obliteration of aortic paravalvular leak
Ali Khan, Peter N Ruygrok, Paisan Nakpathomkun, Ivor L Gerber
A 76-year-old man with symptomatic severe aortic stenosis and coronary disease underwent elective aortic valve replacement (AVR) and two-vessel coronary bypass surgery. During surgery his aortic valve was noted to be severely calcified, particularly in the right coronary and non-coronary sinuses, where it was difficult to achieve complete decalcification.
A 29 mm bovine pericardial prosthetic valve was implanted. The post-bypass transoesophageal echocardiogram (TOE) identified a small paravalvular leak (PVL) in the region of non-coronary sinus where most calcification had been observed. At the time it was felt that further surgical intervention was unlikely to be beneficial.
The patient reported no noticeable improvement of his pre-surgical dyspnoea (NYHA class III) at the 2-month follow-up visit and a prominent aortic early diastolic murmur was audible. A transthoracic echocardiogram showed at least moderate eccentric aortic regurgitation. A subsequent TOE revealed a significant PVL but no valvular regurgitation and the left ventricle appeared to have enlarged.
The patient was re-discussed at the combined cardiology-cardiac surgery meeting and it was felt that the chance of significant morbidity and mortality, associated with re-operation was high, and the potential for benefit doubtful. After discussion with the patient, an attempt to partially obliterate the PVL by a percutaneous transcatheter approach was planned.
The procedure was undertaken under general anaesthesia with TOE and fluoroscopic guidance, preceded by DC cardioversion of atrial fibrillation (AF) to sinus rhythm. Via a retrograde approach from the right femoral artery, a 6 French delivery sheath was advanced across the defect, through which a 10 mm Amplatzer vascular plug was carefully positioned and delivered, with definite angiographic and echocardiographic reduction in the degree of aortic regurgitation (Figure 1). The procedure time was 55 minutes and fluoroscopy time 8 minutes.
The patient tolerated the procedure well with no complications and was discharged the next day on warfarin anticoagulation for recurrent AF. At 6-week follow-up he reported definite symptomatic improvement (NYHA Class II) and a TOE showed stable position of the plug with only a mild-moderate residual PVL (Figure 2).
Early para-prosthetic leakage after AVR is relatively common and may be related to particular valve types,1 but the majority of defects are small and generally have a benign course. Some, however, may cause progressive left ventricular dilatation and heart failure from a high regurgitant load, and may also cause haemolysis. This usually occurs due to incomplete apposition of the sewing ring of the prosthetic valve to the native aortic tissue and suture dehiscence, and develops more commonly in patients with significant annular calcification or localised infection.1,2
The rate of detection of PVL has increased due to improved diagnostic techniques. Doppler echocardiography is particularly useful in differentiating transvalvular from paravalvular regurgitation.3 Until recently, management has been limited to medical therapy or re-operation which has been associated with a high mortality and substantial risk of recurrent paravalvular leak.4
Percutaneous transcatheter closure of aortic prosthetic PVLs has recently been described in selected patients, with a reasonable chance of success. This can however be technically challenging, with only a few case reports in the literature.5,6 Careful assessment of the defect by pre-procedural TOE and peri-procedural selective contrast injection is important in the estimation of defect size and geometry, and in selection of an appropriate obliteration device.
The presence of vegetations or thrombus, active infection or an unstable rocking valve, are clear contra-indications. Obliteration of PVL is feasible in patients with a ‘tilting-disc’ mechanical valve provided care is taken to ensure the device does not interfere with leaflet movement before released. No specifically designed transcatheter device has been developed or approved for percutaneous PVL closure but there are reports of use of the Amplatzer atrial septal occluder, Rushkind umbrella, Cardioseal Clamshell septal occluder, and Gianturco detachable coils.7–9 Larger defects may require more than one device.
In our case we used the Amplatzer device since it is compressible and relatively conformable. Potential procedural complications include interference with valve leaflet movement, embolisation of thrombus, air, atheroma or the device itself, haemolysis, bleeding, and infection.10
With increasing numbers of aortic valve operations being undertaken (particularly in the elderly), the burden of significant PVL requiring repeat intervention will increase. In those patients in whom the risk of re-operation is high, percutaneous obliteration appears to be a technically feasible and safe alternative.
Author information: Ali Khan, Cardiology Registrar, Auckland City Hospital; Peter N Ruygrok, Interventional Cardiologist, Auckland City Hospital; Paisan Nakpathomkun, Interventional Fellow, Auckland City Hospital;
Ivor L Gerber, Cardiologist, Auckland City Hospital; Nicholas Kang, Cardiac Surgeon, Auckland City Hospital; Auckland
Correspondence: Dr Ali Khan, Green Lane Cardiovascular Service, Level 3, Auckland City Hospital, Private Bag 92024, Auckland 1030, New Zealand.
Fax: +64 (0)9 3074950; email: Ali.Khan@waitematadhb.govt.nz
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads)
Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals