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Aortic paravalvular leak closure
Paravalvular leak (PVL) occurs in 5% to 17% of patients after valve replacement surgery. Although the majority of PVLs are subclinical, some patients develop symptoms of heart failure, hemolysis, or both, requiring intervention. Surgical repair or valve re-replacement is the historical gold standard for the management of symptomatic PVL, but is associated with significant morbidity and mortality, even in modern practice. Percutaneous PVL closure has proven to be a feasible alternative to repeat surgery, with safety and efficacy demonstrated in several studies. Techniques and outcomes of percutaneous PVL closure differ significantly according to the prosthesis location (aortic vs. mitral). This chapter focuses on summarizing the contemporary techniques and outcomes of percutaneous aortic PVL closure.
Clinical impact of aortic PVL
The incidence of PVL is higher among patients with mitral prostheses than those with aortic prostheses. It is also higher in patients undergoing transcatheter vs. surgical aortic valve replacement. Although symptomatic aortic PVL is known to negatively affect long-term outcomes, data from the transcatheter aortic valve replacement (TAVR) literature suggest that more than mild aortic PVL is associated with worse long-term survival even in asymptomatic patients. However, in current practice, the majority of patients considered for PVL closure are referred due to heart failure, progressive ventricular dilatation, unexplained dyspnea, or hemolytic anemia. Once the decision is made to offer percutaneous aortic PVL closure to the patient, detailed pre- and intraprocedural imaging assessment is necessary to understand the mechanism and anatomic characteristics of the leak and to select the optimal closure technique.
AHA guidelines
| IIa | B | Percutaneous repair of paravalvular regurgitation is reasonable in patients with prosthetic heart valves and intractable hemolysis or New York Heart Association (NYHA) class III/IV heart failure who are at high risk for surgery and have anatomic features suitable for catheter-based therapy when performed in centers with expertise in the procedure. |
Multimodality assessment of the paravalvular leak
Preprocedural imaging
Procedural success relies on full understanding of the location, number, and severity of PVL(s). Although aortic PVLs are often detected on transthoracic echocardiography (TTE), detailed assessment of their characteristics often requires additional imaging. Transesophageal echocardiography (TEE) provides excellent delineation of the location and the severity of the leak. Cardiac computed tomography (CCT) offers incremental value in identifying the path of the leak, measuring its dimensions, distances from the right and left coronary ostia, and predicting the ideal fluoroscopic angles for the closure procedure ( Fig. 13.1 ). Meticulous planning increases the likelihood of successful closure and decreases the procedure duration, radiation exposure, and contrast use.
We utilize a multifaceted approach incorporating echocardiographic, invasive hemodynamic, and angiographic data to grade the leak to mild, mild to moderate, moderate, and severe. Common echocardiographic parameters used include (1) PVL jet width measured in the short and long axis at the level of the sewing ring and in the left ventricular (LV) outflow tract, (2) diastolic flow reversal in the descending thoracic and abdominal aorta, (3) deceleration rate by pressure half-time, and (4) regurgitant volume and regurgitant fraction. Invasive hemodynamics and aortic root angiography are often used to ascertain the severity of regurgitation in equivocal cases.
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