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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3590_Библиотеки_им_академика_М_И_Перельмана
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17—MITRAL PARAVALVULAR LEAK CLOSURE 197
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defect with the telescoping system, a 0.0320 or 0.0350 Amplatz extra-stiff long-exchange wire
with an LV-shaped curve is advanced in the LV. The telescoping system will be exchanged for a
7 to 8F Flexor Shuttle Sheath positioned across the defect. While the wire is in place, the AVP
II device is deployed and the sheath is withdrawn. The sheath will then be reloaded over the
guidewire outside the body to allow for delivery of additional adjacent devices in sequence, while
the initial AVP II device is still attached to its cable outside the sheath (Fig. 17.5).
A
C
Fig. 17.5 Sequential deployment of Amplatz Vascular Plugs (AVP) using the anchor wire technique. (A) Stillframe left anterior oblique and caudal fluoroscopic image demonstrates successful crossing with an antegrade
transseptal approach anterolateral to the PVL defect using a coaxial telescoping system over the extra-support,
exchange-length 0.0350 angled Glidewire. (B) The coaxial telescoping system was exchanged for an 8F shuttle
sheath over the exchange-length, extra-stiff 0.0350 Amplatz wire looped in the left ventricle to allow for sequential deployment of AVP II devices. (C) Once the first device is extruded in the annular defect, the shuttle sheath
is removed from the body and reloaded over the Amplatz wire to deliver additional devices sequentially and
adjacent to the prior plug. This still-frame image demonstrates the deployment of three adjacent AVP II plugs
that are ready to be released from their cables if the devices are stable and no leaflet impingement is seen.
(D) Still-frame image shows the successful release of three AVP II plugs (red arrow) in the anterolateral defect
using the anchor wire technique. Another more posteriorly located defect was crossed using the transseptal
antegrade approach and one AVP II device (yellow device) was deployed while having an anchor wire looped
in the left ventricle.
B
D
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Sequential Deployment (Arteriovenous Rail)
In cases where increased support is needed to cross the defect, an arteriovenous rail will be
formed. The extra-support, exchange-length angled hydrophilic wire is snared after crossing the
defect in the ascending aorta and externalized through the femoral artery sheath. This technique
requires two operators and Hemostats to secure the wire from both ends. Once the rail is formed,
the delivery system can be exchanged for a Flexor Shuttle Sheath that can be advanced through
the defect over the stable rail system. Through the sheath an AVP can be advanced and deployed
while it is still attached to its cable. The Flexor Shuttle Sheath can then be removed from the
body and reloaded over the rail system outside the initial AVP cable to allow for deployment of
an additional AVP in sequence (Fig. 17.6).
A
Fig. 17.6 Sequential deployment over a stable arteriovenous rail system. (A) Still frame of right anterior
oblique angulation fluoroscopic image illustrates 6F guide advanced across the mitral paravalvular leak (PVL)
defect via a standard transseptal antegrade approach. (B) The exchange-length angled Glidewire (blue arrow)
was externalized using a 6Fr en snare device (yellow arrow) inserted through the femoral artery sheath to
create an arteriovenous (AV) rail. (C) The coronary guide was exchanged for a 7F shuttle sheath to allow for
sequential deployment of multiple AVP II devices over the AV rail (blue arrow). The first 12-mm AVP II device
was extruded out of the shuttle sheath. (D) The shuttle sheath was removed from the body and reloaded on
the AV rail to allow delivery of a second AVP II 10-mm device adjacent to the first device. Both devices are
still attached to their cable, allowing reversibility of the steps. The steps can be repeated if additional plugs
are needed to fully seal the defect.
B
17—MITRAL PARAVALVULAR LEAK CLOSURE 199
AB
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If there is difficulty crossing the defect after multiple devices are deployed, a smaller (6 to 7F)
shuttle sheath can be utilized for a lower crossing profile, especially if smaller devices are required
to seal the defect. The rail system provides stability and allows for device retrieval if desired while
AVP devices are still attached to their cables. Caution and continuous hemodynamic monitoring
and wire assessment are required with this method, as constant tension in the rail system can lead
to significant valvular interaction and potentially aortic regurgitation that can be alleviated by
releasing the wire tension.
Sequential Deployment (Transapical Rail)
Transapical puncture can be performed in patients with double mechanical valves if extra support
provided by the rail system is required for successful closure. Transapical puncture can be
performed with a combination of TTE/TEE and fluoroscopy guidance using a 19-gauge, 20-cm
angio-needle over which a Teflon catheter is advanced into the LV. A 4F sheath can then be
advanced over short 0.0350 short guidewire carefully (Fig. 17.7). The extra-support angled
Fig. 17.7 Sequential deployment of devices over a transapical (TA) rail in a patient with double mechanical
valves. (A) A 6F Amplatz goose neck snare (yellow arrow) through a 6F transapical sheath was used to
externalize the exchange-length Glidewire after crossing the mitral PVL defect in the standard antegrade
transseptal fashion. (B) Still-frame left anterior oblique and caudal fluoroscopic image illustrates sequential
delivery of 12-mm AVP II through a posterolateral defect over a stable TA rail system. (C) TA rail allows for
sequential plug delivery similar to the AV rail and anchor wire techniques. (D) Hemostasis of TA puncture site
was achieved with 6-mm AVP II device at the end of the case because a 6F sheath was used for the LV
puncture site.
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hydrophilic wire can be externalized and used as a rail for antegrade delivery of sheaths and plugs
through the transseptal approach, as previously described. At the end of the procedure, hemostasis can be achieved with manual pressure of the 4F sheath system entry site after reversal of
heparin with protamine. For retrograde delivery of devices, a 6F sheath is used for the transapical
access site, and hemostasis is usually achieved with a 6- to 8-mm AVP II plug deployment.
Retrograde Approach
Crossing can be achieved using a retrograde approach from the ventricular side across the mitral
PVL defect and is sometimes necessary due to smaller defects that course under the sewing ring. A
retroflexed catheter (e.g., Amplatz left or left coronary bypass catheters) with the long-exchange,
extra-support angled hydrophilic wire can be used to cross the defect. The wire can be snared in the
LA and externalized via transseptal access to create the arteriovenous rail. The sheath and device
can then be delivered in antegrade fashion, as described earlier, over the rail system (Fig. 17.8).
AB
C
Fig. 17.8 Retrograde crossing of mitral PVL defect after an unsuccessful antegrade transseptal attempt.
(A) Right anterior oblique fluoroscopic still-frame image illustrates retrograde crossing of mitral paravalvular
leak (PVL) defect with exchange-length, extra-support angled Glidewire (red arrow) delivered by diagnostic
coronary catheter (blue arrow) through the femoral artery. The wire was snared into an 8.5F Agilis sheath
(yellow arrow) in the left atrium and externalized to create a stable arteriovenous (AV) rail. (B) Antegrade transseptal crossing of mitral PVL with 8F Flexor Shuttle Sheath (red arrow) was then performed over the stable
AV rail. The AV rail system was then exchanged for two 0.0350 exchange-length, extra-stiff Amplatz wires
(yellow arrow) parked in the descending aorta. (C) The Shuttle Sheath was then exchanged for two coaxial
telescoping systems loaded separately on the 0.0350 Amplatz wires to allow for simultaneous plug deployment (“double-wire technique”). (D) Two 8-mm AVP IV devices (yellow arrow) were extruded simultaneously
in the PVL defect.
D
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Transapical puncture can be used for retrograde delivery of devices in certain cases when the
atrial septum is not suitable for transseptal delivery of guides and sheaths, such as in cases with
previous device closure of the septum. In addition, certain defects, such as medially located mitral
PVL, might be difficult to access with an antegrade transseptal approach due to the short distance
and difficult steerability of the delivery system across the atrial septum. The defect can be crossed
and the device delivered and deployed in a retrograde fashion. Transapical access carries a risk for
hemothorax and the potential need for chest tube instrumentation, especially when larger sheaths
are utilized (e.g., 6F sheath system).
Complete resolution of mitral PVL is important for treatment of hemolytic anemia, while
residual #11 regurgitation is usually acceptable for improving heart failure symptoms. In the
Mayo Clinic mitral PVL closure experience, three out of four patients were free of heart failure
symptoms or the need for surgical repair over 3 years after successful PVL closure.
8
Mitral PVL Closure After Transcatheter Mitral Valve
Replacement
With the growing field of transcatheter mitral valve replacement, mitral PVL is expected to increase, and transcatheter closure techniques will be highly useful. In general, similar techniques
can be used for PVL of transcatheter mitral valve devices; however, a detailed understanding of
the transcatheter valve anatomy and differences between surgical prosthesis structure and anchoring is necessary to avoid injury to transcatheter valve leaflets or disruption of transcatheter valve
anchoring through paravalvular leak catheter crossing (Fig. 17.9).
C
Fig. 17.9 Paravalvular leak (PVL) closure after transcatheter Edwards SAPIEN placement in mitral annular
calcification. (A) Right anterior oblique still-frame fluoroscopic image demonstrates antegrade crossing
of delivery catheter and extra-support 0.0350 angled Glidewire through the cells of the SAPIEN cage (yellow
arrow). (B) The delivery catheter and wire were withdrawn and successfully advanced through the defect. The
figure illustrates that the delivery catheter is through the defect away from the SAPIEN cage. (C) The AVP II
device was successfully extruded through the defect without interaction with the SAPIEN valve.
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Pitfalls and Managing Complications
Awareness and avoidance of complications before they occur is essential. Leaflet impingement
(≈
4%), device embolization (,1%), and cardiac perforation (≈ 1%) are key complications to
watch for during the procedure.9 Leaflet impingement can be avoided by careful examination
of prosthetic leaflet motion via fluoroscopy and 3D TEE while extruding the device. If it
occurs, repositioning the same device or use of smaller devices might be necessary to avoid
prosthetic valve malfunction (see Fig. 17.9). Device embolization can be prevented by pushing
on the device with the guide and performing a tug test by pulling on the cable to ensure
stability of the device before its release. If the device is pulled and pushed with ease through
the defect, it is important to remove it from the body and exchange for a larger one. If left
atrial embolization occurs, snaring can be performed directly from the transseptal access. If
systemic embolization occurs, snaring of the device can be performed using the alternative
femoral access site (Fig. 17.10).
Bleeding complications can be reduced by safe practice of transseptal access using fluoroscopy
and TEE guidance, arterial and venous access using ultrasound and fluoroscopy guidance, and use
of vascular closure devices. Transapical puncture should be avoided unless there is no alternative,
as it is associated with ≈
a significant learning curve
conjunction with experienced operators.
20% risk of hemothorax. Most importantly, mitral PVL closure has
10
; and it is recommended that the first 50 cases be performed in
AB
Fig. 17.10 Still-frame fluoroscopic images of device embolization into the systemic circulation. (A) Iliac angiography via contralateral access demonstrates 10-mm AVP II device embolization to the left external iliac
artery with occlusion of the vessel. (B) Still-frame fluoroscopic image demonstrates successful retrieval of the
device with bioptome through a 10F ipsilateral femoral sheath after previous failed retrieval attempts with a
6F en snare catheter.
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Procedural Steps for Paravalvular Leak Closure
Figs. 17.11 through 17.21 show the steps necessary for PVL closure.
Future Directions
Due to an aging population and increased utilization of transcatheter mitral valve replacement to
treat native and bioprosthetic mitral valve dysfunction, the need for mitral PVL closure will likely
increase in the upcoming years. Integrating invasive hemodynamics, if used effectively, might
provide further procedural guidance and prognostic information.
technology, such as fusion of CT and fluoroscopy imaging in the catheterization laboratory, and
the development of specific devices targeted for PVL treatment may further improve procedural
success.
11
Advancement in imaging
Fig. 17.11 Antegrade transseptal approach. Transseptal
puncture is performed under TEE guidance.
Fig. 17.12 An Inoue wire is placed in the left atrium and
used to advance an Inoue dilator across the intraatrial
septum.
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Fig. 17.13 A steerable and flexible sheath, such as an
8.5F Agilis, is advanced in the left atrium, and a coaxial
telescoping system of mother-daughter catheters is advanced into the left atrium (LA). An exchange-length,
extra-support angled hydrophilic 0.0350 wire is advanced
through the telescoping system and torqued to probe the
defect until it passes through the paravalvular prosthetic
leak (PVL).
Fig. 17.14 Once the defect has been crossed and passage through the paravalvular prosthetic leak (PVL) is
confirmed on transesophageal echocardiography (TEE)
and fluoroscopy, the wire is advanced and positioned in
a safe place (usually in the ascending aorta in the
absence of a mechanical aortic prosthesis). The 5F diagnostic catheter and then the guide are then advanced
into the left ventricle (LV) across the defect.
Fig. 17.15 Once the defect has been crossed with the
telescoping catheter system, the stiff angled Glidewire
and 5F catheter are removed. The most commonly used
AVP II are #12 mm and can be delivered through the 6F
coronary guide without difficulty.
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Fig. 17.16 If larger devices or multiple devices are re-
quired in a nested fashion, the telescoping system can
be exchanged for a shuttle sheath over a 0.0320 or
0.0350 Amplatz exchange-length, extra-stiff guidewire
looped in the left ventricle (LV) (see anchor wire technique
section later).
Fig. 17.17 In patients with very large defects in which
more than one AVP device is needed, a double-wire
technique can be used. In this technique, a larger-access,
≈ 20F venous sheath is needed. Once the defect is
crossed with the telescoping system, two to three 0.0320
Amplatz long-exchange, extra-stiff guidewires can be
advanced and looped in the left ventricle (LV). Two to
three separate telescoping systems of 6F guides and 5F
multipurpose catheter can be advanced, each over a
separate Amplatz wire into the LV. After removal of the
multipurpose catheter, multiple AVP II #12 mm can
be positioned in the defect and deployed, as previously
described.
Fig. 17.18 The anchor wire technique is most com-
monly used for defects that require more than one plug
but are not large enough to accommodate multiple
catheters over double wires. After crossing the defect
with the telescoping system, a 0.0350 Amplatz extra-
stiff, long-exchange wire with a left ventricle (LV)-shaped
curve is advanced in the LV. The telescoping system is
exchanged for a 7F to 8F Flexor Shuttle Sheath posi-
tioned across the defect. While the wire is in place, the
AVP II device is deployed and the sheath is withdrawn.
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Fig. 17.19 The sheath will then be reloaded over the guidewire outside the body to allow for delivery of additional adjacent devices in sequence, while the initial AVP II device is still attached to its cable outside the
sheath.
Fig. 17.20 In cases where increased support is needed to cross the defect, an arteriovenous rail will be
formed. The extra-support, exchange-length angled hydrophilic wire is snared after crossing the defect in the
ascending aorta and externalized through the femoral artery sheath. This technique requires two operators
and Hemostats to secure the wire from both ends. Once the rail is formed, the delivery system can be exchanged for a Flexor Shuttle Sheath that can be advanced through the defect over the stable rail system.
Through the sheath an AVP can be advanced and deployed while it is still attached to its cable. The Flexor
Shuttle Sheath can then be removed from the body and reloaded over the rail system outside the initial AVP
cable to allow for deployment of additional AVPs in sequence.
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