Download Repair of Prosthetic Mitral Valve Paravalvular Leak Using an Off

Repair of Prosthetic Mitral Valve
Paravalvular Leak Using an OffPump Transapical Approach
Vinod H. Thourani, MD, Colleen M. Smith, BA,
Robert A. Guyton, MD, Peter Block, MD,
David Liff, MD, Patrick Willis, MD,
Stamatios Lerakis, MD, Chesnal D. Arepalli, MD,
Sharon Howell, RDCS, Bryon J. Boulton, MD,
James Stewart, MD, and Vasilis Babaliaros, MD
Division of Cardiothoracic Surgery, Joseph B. Whitehead
Department of Surgery; Division of Cardiology, Department of
Medicine; and Department of Cardiothoracic Imaging, Emory
University School of Medicine, Atlanta, Georgia
Patients who present with significant paravalvular
regurgitation after mitral valve replacement remain a
difficult patient population and high-risk surgical candidates. We present 3 cases of transapical closure of
mitral valve paravalvular leak (PVL) after mitral valve
replacement using Amplatzer closure devices (AGA
Medical Corp, Plymouth, MN). All 3 patients experienced decreased regurgitation at the site of the closure
as well as symptomatic improvement in their heart
failure.
(Ann Thorac Surg 2012;94:275–78)
© 2012 by The Society of Thoracic Surgeons
A
lthough uncommon, paravalvular leak (PVL) of previously replaced mitral valves has a reported incidence of 3% to 12.5%. Most leaks become apparent in the
first 6 months after the original procedure, but many
patients remain asymptomatic and do not require further
surgical intervention. However symptomatic patients often have associated heart failure, hemolytic anemia,
arrhythmias, and infective endocarditis [1].
Many patients with symptomatic PVL will benefit
from a second surgical intervention by sternotomy or
right thoracotomy for repair of the PVL or replacement
of the valve in patients with an unstable prosthesis.
However in patients considered very high risk for an
open surgical procedure, the best method of treatment
for mitral valve PVL remains a difficult clinical scenario. An alternative technique for repair of the anterolateral mitral valve PVL in this patient population
has been the transfemoral approach. For some patients
with a PVL in the posterolateral or posteromedial
(septal) portion of the mitral valve prosthesis, access to
the defect using the transfemoral approach is particularly difficult.
Here we present 3 high-risk patients with mitral valve
PVLs who underwent repair using a transapical ap-
Accepted for publication Dec 6, 2011.
Address correspondence to Dr Thourani, Division of Cardiothoracic
Surgery, Joseph B. Whitehead Department of Surgery, Emory University
Hospital Midtown, 550 Peachtree St, 6th Flr, Medical Office Tower,
Atlanta, GA 30308; e-mail: [email protected].
© 2012 by The Society of Thoracic Surgeons
Published by Elsevier Inc
CASE REPORT
THOURANI ET AL
TRANSAPICAL MV PARAVALVULAR LEAK REPAIR
275
proach with Amplatzer ventricular septal defect (VSD) or
patent ductus arteriosus occluders.
Case Reports
Surgical Technique
Initially, femoral venous and arterial access was obtained
using 6F catheters. The patients then underwent an
epicardial ultrasonographically guided left minithoracotomy incision. Two U mattress sutures were placed in
the anterolateral portion of the heart, close to the second
diagonal coronary artery. Left ventricular access was
achieved and a 0.035-inch Terumo wire was used to cross
the PVL into the left atrium. A 14F sheath was placed within
the left atrium followed by 2 Amplatz extra-stiff wires (0.035
inch). Care was taken to land the tips of these wires
within the left atrium and not into the pulmonary veins.
Although a 14F sheath is not always required, it is helpful
when placing 2 Amplatzer devices simultaneously. Intraoperative transesophageal echocardiography (TEE) was
used to guide crossing of the PVL, sizing of the PVL with
angioplasty balloon, placement of the Amplatzer device,
and assessment of resolution of the PVL before closure
(Fig 1). All procedures were performed without cardiopulmonary bypass and all patients were extubated on
postoperative day 0.
Patient 1
Our first patient was a 61-year-old woman with a history
of rheumatic heart disease, transient ischemic attack,
hypertension, atrial fibrillation, and a mechanical mitral
valve, who had previously undergone 3 mitral valve
replacements (1 with concomitant aortic valve replacement). She presented with New York Heart Association
(NYHA) class IV heart failure and severe hemolytic
anemia and was found to have a PVL on the posterolateral mitral valve annulus by TEE.
A transfemoral transcatheter approach was initially
attempted to repair the PVL, but the attempt was aborted
because of the unfavorable angulation of the pathway of
the leak across the bioprosthesis into the left ventricle.
The patient was then taken to the hybrid operating room,
where a transapical approach was used to repair the leak
with a 6-mm Amplatzer VSD occluder device, after which
the leak showed a decrease from ⫹4 to ⫹2, and 3-dimensional (3D) TEE showed the device to be correctly
deployed.
Postoperatively the patient required blood transfusions and was given erythropoietin for her hemolytic
anemia. Follow-up echocardiograms documented decreasing PVL until 9-month follow-up when no residual
leak was noted and the hemolytic anemia had resolved.
The patient experienced a decrease in her NYHA symptoms from class IV at the time of operation to class II by
the 20-month follow-up.
Patient 2
Patient 2 was a 59-year-old woman with a history of
morbid obesity, insulin-dependent diabetes mellitus
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2011.12.035
FEATURE ARTICLES
Ann Thorac Surg
2012;94:275–78
276
CASE REPORT
THOURANI ET AL
TRANSAPICAL MV PARAVALVULAR LEAK REPAIR
Ann Thorac Surg
2012;94:275–78
Fig 1. Fluoroscopy demonstrating (A) positioning of the ventricular septal defect (VSD)
closure device (arrow), (B) left atrial deployment (arrow), (C) left ventricular deployment
(arrow), and (D) final results (arrow).
FEATURE ARTICLES
type 2, hypertension, and a porcine mitral valve and had
previously undergone 2 mitral valve replacements. She
presented with NYHA class III heart failure and was
found to have a severe posteromedial mitral valve PVL
by TEE (Fig 2A). This patient was at high risk of morbidity with redo sternotomy; furthermore the location of her
PVL as well as her obesity made a transfemoral percutaneous approach unlikely to be successful. Therefore she
Fig 2. (A) Transesophageal echocardiography (TEE) showing preoperative paravalvular leak (PVL). (B) TEE showing postoperative PVL.
(C) Three-dimensional TEE showing postoperative double device closure (solid and dashed arrow).
Ann Thorac Surg
2012;94:275–78
underwent a transapical repair of the leak using both a
10-mm Amplatzer VSD occluder device and a 12-mm/
10-mm Amplatzer patent ductus arteriosus occluder device. Intraoperative 3D TEE demonstrated a decrease in
the PVL from severe to mild and showed that both
devices were appropriately located (Figure 2B and C). At
3-month follow-up, the patient’s symptoms of heart failure had decreased from NYHA class IV to class II.
Patient 3
277
with symptoms of NYHA class IV heart failure and was
found to have a severe posteromedial mitral valve PVL
adjacent to the atrial septum as well as a mild anterolateral jet seen by TEE and cardiac magnetic resonance
imaging (MRI) (Fig 3A and B). Because of the severe
leak’s location in proximity to the atrial septum and the
history of severe mitral annular calcification, a transapical approach was deemed the more appropriate surgical
option. Repair was performed using a 10-mm Amplatzer
VSD occluder device. Intraoperative TEE demonstrated a
decrease in severity of the PVL from severe to minimal,
with an appropriately positioned device (Fig 3C).
At discharge the patient’s symptoms of heart failure
had decreased from NYHA class IV to class I. A postoperative cardiac MRI demonstrated no evidence of PVL at
the site of the Amplatzer device, although it continued to
demonstrate a mild PVL at the lateral mitral valve annulus (Fig 3D). At the 6-month follow-up, the patient was in
FEATURE ARTICLES
Our third patient was a 53-year-old man with a history of
hypertension and a porcine mitral valve who had previously undergone concomitant mitral valve replacement
and coronary artery bypass of a saphenous vein graft to
the posterior descending coronary artery. He had a
history of a heavily calcified posterior mitral valve annulus, and successful replacement of his valve was considered unlikely with another open operation. He presented
CASE REPORT
THOURANI ET AL
TRANSAPICAL MV PARAVALVULAR LEAK REPAIR
Fig 3. (A) Preoperative cardiac magnetic resonance imaging (MRI) (true fast imaging with steady state precession [trueFISP] image) showing
posteromedial paravalvular leak (PVL) (arrow). (B) Preoperative transesophageal echocardiography (TEE) showing severe posteromedial PVL
(solid arrow) and mild anterolateral PVL (dashed arrow). (C) Postoperative TEE showing VSD device closure of posteromedial PVL (arrow).
(D) Postoperative cardiac MRI (trueFISP image) showing closed posteromedial PVL (solid arrow) and persistent anterolateral PVL (dashed
arrow).
278
CASE REPORT
THOURANI ET AL
TRANSAPICAL MV PARAVALVULAR LEAK REPAIR
NYHA class I, but on follow-up MRI his PVL in the
anterolateral aspect of the mitral valve had increased to
moderate, although he had no evidence of PVL at the site
of repair.
Comment
FEATURE ARTICLES
The American Heart Association consensus guidelines
include a class I recommendation for mitral valve surgical procedures in patients with chronic, severe mitral
regurgitation and NYHA functional class II, III, or IV
symptoms in the absence of severe left ventricular dysfunction [2]. In stable patients with prosthetic valve
dysfunction, repeated traditional mitral valve replacement is the recommended treatment for PVL. However
reoperation for repair of PVL is associated with higher
morbidity and mortality than the original procedure,
with in-hospital mortality rates of 13%, 15%, and 37% for
the first, second, and third reoperations, respectively [3].
In addition, each reoperation carries an increased risk of
recurrence of the leak. Therefore alternative approaches
may be considered in patients who have undergone
multiple sternotomies, have hostile mediastinum, have a
history of coronary artery bypass grafts that cross the
midline, have other significant risk factors that preclude
a repeated sternotomy, or who cannot tolerate cardiopulmonary bypass.
The most common alternative approach remains the
percutaneous transfemoral transseptal repair [1]. When
performing a transfemoral mitral valve PVL repair, an
antegrade transseptal or retrograde (through the aortic
valve) approach, or both, may be used. This technique
avoids a thoracotomy and has been performed with
technical success rates of 60% to 90% in selected patients
[1]. It is of note that a retrograde approach is precluded in
patients who have received a previous mechanical aortic
valve.
Limited data exist on the outcomes of transfemoral
mitral valve PVL repairs; with available series reporting
at most 10 to 27 patients [1, 4, 5]. These series show
success in eliminating or reducing the PVL, leading to
improvement of heart failure symptoms. Hemolytic anemia was reported to have resolved in 60% to 83% of
patients [1]. A small number of patients who did not
require blood transfusions before the procedure manifested transfusion-dependent hemolytic anemia after
placement of the PVL closure device.
There are some additional reports of adverse outcomes
after transfemoral catheter repair of PVLs, including
stroke, arrhythmia, cardiac perforation, interference of
the new device with function of the mitral valve, late
device dislodgement, and renal failure [1, 5–7]. In the
event of inadequate closure, a second transcatheter attempt can be made or patients can undergo definitive
surgical intervention at no increased risk after the
catheterization.
Very few reports are available describing the
transapical approach as used in our patients [7, 8].
These cases suggest that posterior and septal mitral
Ann Thorac Surg
2012;94:275–78
valve PVL are difficult to approach transfemorally and
therefore a transapical approach may be preferred. The
transapical approach provides direct access to the
mitral valve and avoids traversing the aorta or aortic
valve. Other advantages to this approach are that it
allows for the passage of a larger catheter so that
multiple devices can be deployed simultaneously to
close large defects. Secondary to the direct approach,
these cases can be performed in less than 1 to 2 hours
and may result in less fluoroscopy time.
Importantly, there are very few perioperative deaths
reported as a result of transcatheter PVL repair despite
the fact that it is commonly attempted in more high-risk
patients [1]. None of the available reports of PVL repair
using the transapical approach indicate perioperative
mortality. Although the outcomes of both transfemoral
and transapical approaches are similar, these procedures
could benefit from the development of specific devices to
facilitate leak closure.
These results suggest that for select patients, transapical repair is a safe and effective option for treatment of
symptomatic mitral valve prostheses PVL. Although this
technique should not substitute for open surgical repair
of mitral valve PVL in low- or medium-risk patients or in
those with an unstable prosthesis, it does provide physicians an alternative treatment for this difficult high-risk
patient population.
References
1. Latson LA. Transcatheter closure of paraprosthetic valve
leaks after surgical mitral and aortic valve replacements.
Expert Rev Cardiovasc Ther 2009;7:507–14.
2. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused
update incorporated into the ACC/AHA 2006 guidelines for
the management of patients with valvular heart disease: a
report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Writing
Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). Circulation
2008;118:e523– 661.
3. Echevarria JR, Bernal JM, Rabasa JM, Morales D, Revilla Y,
Revuelta JM. Reoperation for bioprosthetic valve dysfunction.
A decade of clinical experience. Eur J Cardiothorac Surg
1991;5:523– 6.
4. Shapira Y, Hirsch R, Kornowski R, et al. Percutaneous
closure of perivalvular leaks with Amplatzer occluders:
feasibility, safety, and shortterm results. J Heart Valve Dis
2007;16:305–13.
5. Moscucci M, Deeb GM, Bach D, Eagle KA, Williams DM.
Coil embolization of a periprosthetic mitral valve leak
associated with severe hemolytic anemia. Circulation 2001;
104:E85– 6.
6. Ussia GP, Scandura S, Calafiore AM, et al. Images in cardiovascular medicine. Late device dislodgement after percutaneous closure of mitral prosthesis paravalvular leak with Amplatzer muscular ventricular septal defect occluder.
Circulation 2007;115:e208 –10.
7. Lim DS, Ragosta M, Dent JM. Percutaneous transthoracic
ventricular puncture for diagnostic and interventional
catheterization. Catheter Cardiovasc Interv 2008;71:915– 8.
8. Lang N, Kozlik-Feldmann R, Dalla Pozza R, et al. Hybrid
occlusion of a paravalvular leak with an Amplatzer septal
occluder after mechanical aortic and mitral valve replacement. J Thorac Cardiovasc Surg 2010;139:221–2.