Principles of Percutaneous Paravalvular Leak Closure
The following are 10 points to remember about percutaneous paravalvular leak closure:
1. Paravalvular regurgitation affects 5-17% of all surgically implanted prosthetic heart valves. Patients with paravalvular regurgitation may present with congestive heart failure or hemolytic anemia.
2. Percutaneous closure should be considered for closure of clinically symptomatic paravalvular leaks unless contraindicated by factors such as unfavorable anatomy, endocarditis, or valve dehiscence.
3. Most paravalvular defects are crescentic, serpiginous, and irregular, and high-quality imaging is essential for guiding closure. Mitral paravalvular leak closure is facilitated by use of 3D echocardiography, whereas transesophageal echocardiography and/or intracardiac echo are useful adjuncts to biplane fluoroscopy for patients with periaortic valves.
4. All efforts must be made to minimize the total radiation exposure given the length of the procedure and need for biplane fluoroscopy. Use of a low-dose setting and lower frame rates can help reduce the radiation dose without compromising visual guidance.
5. Paramitral defects comprise 80% of the cases in the experience of the authors. Multiple approaches to paramitral defects are utilized, including antegrade transseptal, retrograde transaortic, and retrograde transapical.
6. For closure for paramitral leaks, the gantries are oriented so that the right anterior oblique projection shows the sewing ring tangentially (or on its side) and the left anterior oblique–caudal view shows the valve enface.
7. For smaller, rounder defects, a single device usually suffices, and the authors prefer the Amplatzer Vascular Plug II. With crescentic or oblong defects, the authors favor a multiple device technique. The preferred approach is simultaneous delivery, although sequential delivery can be used if needed.
8. Para-aortic defects are best approached retrograde. Many of these defects are anterior and are best visualized in the lateral projection. Most para-aortic defects are small and can be closed with a single device.
9. Use of atrioventricular (AV) loops (created by snaring the wire and externalizing it) or direct apical puncture may be required in certain cases to facilitate device delivery.
10. Complications of the procedure include obstruction of the titling valve leaflet, embolization of the device, coronary artery obstruction, or stroke. The authors describe a decrease in complications with increasing experience.
Keywords: Prostheses and Implants, Echocardiography, Three-Dimensional, Heart Valve Prosthesis, Stroke, Fluoroscopy, Endocarditis, Punctures, Heart Failure, Coronary Vessels, Heart Valves, Echocardiography, Transesophageal
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