Transcript Dia 1 - ACHD Learning Center

Adult Congenital Heart Disease
Basic Teaching Course
ACHD Curriculum:
Case Lessons in Catheterization
Percutaneous Treatment of Paravalvular
Leaks
Chad Kliger, MD, MS
Assistant Professor, Hofstra School of Medicine
Vladimir Jelnin, MD
Director of Cardiac CT Imaging Laboratory
Carlos E. Ruiz, MD, PhD
Professor, Hofstra School of Medicine
Lenox Hill Hospital North Shore LIJ
ISACHD Congenital Heart Disease Basic Course
Case Objectives
• Illustrate a case of symptomatic prosthetic
paravalvular regurgitation treated with percutaneous
closure
• Discuss the basic principles, imaging modalities,
outcomes, and complications for percutaneous
closure
• Describe transcatheter techniques of closure with a
focus on percutaneous transapical access
ISACHD Congenital Heart Disease Basic Course
Case Summary
• 48 year old male
• Mitral regurgitation s/p repair 11/2009 complicated
•
•
•
•
with severe systolic anterior motion/left ventricular
outflow tract obstruction
S/p bioprosthetic mitral valve replacement 6/2010
Infective endocarditis 7/2011 requiring aortic and redo
mitral valve replacements (St Jude Mechanical, aortic
#23, mitral #27)
Presents with severe congestive heart failure NYHA III
and hemolytic anemia requiring blood transfusions
every 2-3wks for last 5 months
Denies fevers, chills; labs including blood cultures and
Gallium/SPECT scan were unremarkable
ISACHD Congenital Heart Disease Basic Course
Case Summary
• Physical Exam:
• BP 116/80, HR 80, RR 12, 98% RA
• Mild scleral icterus, +JVD 8cm
• Mechanical S1/S2, 3/6 holosystolic murmur at apex
•
radiating to axilla
• Decreased breath sounds bilateral bases 1/3 up
• Trace bilateral lower extremity edema
Labs:
• Hemoglobin 8.3 g/dL, haptoglobin <8 mg/dL, NT
proBNP 3193 pg/mL, LDH 40,000 U/l, INR 2.3, total
bilirubin 2.2 mg/dL
ISACHD Congenital Heart Disease Basic Course
Transesophageal
Echocardiogram
ISACHD Congenital Heart Disease Basic Course
Computed Tomographic
Angiography 3D/4D
ISACHD Congenital Heart Disease Basic Course
Percutaneous Transapical
Mitral PVL Closure
• CTA-fluoroscopy fusion imaging (HeartNavigator, Philips) for guidance
• Simultaneous delivery of AVP II 8mm x2 devices; transapical closure
using an AVP II 8mm
ISACHD Congenital Heart Disease Basic Course
Post-Procedural CTA
ISACHD Congenital Heart Disease Basic Course
Background
• PVL(s) result from an incomplete seal between
•
•
•
sewing ring and annulus
Risk factors for PVL
• Annular calcification, tissue friability
• Infection
• Suturing technique
• Size and shape of prosthetic implant
Surgical valve replacement
• 2-10% in aortic position, 7-17% in mitral position
Transcatheter aortic valve replacement
• Moderate PVL in 13.5% (Sapien, Edwards) and 19.9%
(CoreValve, Medtronic)
Gilard et al. NEJM 2012
ISACHD Congenital Heart Disease Basic Course
Background
• 80% of surgical PVLs referred for closure are in the
•
•
•
•
mitral position
1-5% of patients with PVL are symptomatic
Symptoms:
• Congestive heart failure (~90% of cases, NYHA ≥3)
• Hemolysis
• Combination (CHF+Hemolysis)
Aortic: Posterior (non-coronary) cusp is most common,
followed by left cusp
Mitral: Inter-trigonal (10 to 1o’clock) and posteroseptal
(1 to 6o’clock) are most common
ISACHD Congenital Heart Disease Basic Course
Imaging of PVL
• Echocardiography:
•
•
•
Transthoracic (TTE) and transesophageal (TEE) can determine
the spatial characteristics along with prosthetic valve function
3D TEE is superior to 2D TEE, providing improved localization
and analysis of shape and size
Color Doppler can localize regurgitation and assess severity
• Computed Tomography:
•
•
•
3D/4D reconstruction using volume rendering techniques
With adjustment of opacity and color and applying cut-planes,
can provide localization and analysis of shape and size
Assists with technical planning for closure
ISACHD Congenital Heart Disease Basic Course
Devices/Technique
•
•
•
•
•
Transcatheter techniques provide a less-invasive approach to
closure compared to surgery
Absence of dedicated devices for percutaneous closure
•
Off-label use of Amplatzer family of devices
Shapes: oval/round vs. crescentic or indeterminate
Serpiginous tracks
Technique of: multiple smaller devices, simultaneous or
sequential delivery (better conformation to PVL)
Kliger et al. EHJ 2012.
ISACHD Congenital Heart Disease Basic Course
Access Sites for
PVL Closure
Arterio-venous
Veno-ventricular
Arterio-ventricular
• Order of approach: most to least likely
•
•
Mitral: retrograde transapical (institution dependent), antegrade
transseptal, and retrograde transaortic
Aortic: retrograde transaortic, antegrade transapical, and
antegrade transseptal
• Creation of an exteriorized rail: complete control/support
Dudiy et al. SHD Interventions. Lippincott 2012.
ISACHD Congenital Heart Disease Basic Course
Case Series of
Percutaneous Closure
Author
Hourihan
Pate
Hein
Shapira
Sorajja
Cortes
GarciaBorbolla
Fernandez
Nietlispach
Sorajja1
Ruiz2
AVG
Technical Clinical
Year Pts PVLs Success Success
1992
2006
2006
2007
2007
2008
2009
3
10
21
11
16
27
8
3
10
26
13
19
27
8
3(100%) 2(67%)
7(70%) 4(57%)
24(92%) 14(67%)
11(85%) 6( 54%)
17(89%) 12(75%)
17(63%) 10(59%)
5(63%) 4(80%)
2010 5
2011 11
5
2011 43
5
141
5(100%) 5(100%)
133(94%) 88(77%)
57
49(86%) 37(89%)
88%
59%
ISACHD Congenital Heart Disease Basic Course
Summary of Complications
Author
Hourihan
Pate
Hein
Cortes
Alonso-Briales
Garcia-Borbolla
Sorajja
Ruiz
(Non-Transapical)
Complications
Hemolysis + migration (1, 25%)
Device dislodgement requiring sx (1, 10%)
Persistent hemolysis (2, 20%)
Retroperitoneal bleeding (1,10%)
Endocarditis (1, 4.7%)
Device interference with valve requiring sx (1, 4.7%)
Hemolysis requiring sx (2, 9.4%)
Ventricular arrhythmia requiring cardioversion (1, 3.7%)
Transient asystole (1, 3.7%)
Bleeding events (5, 1.9%)
Cerebrovascular events (2, 7.4%)
Pericardial effusion (1, 3.7%)
Residual shunts (3, 37.5%)
Residual shunt requiring surgery (1, 12.5%)
Massive stroke/death (1, 12.5%)
Death (2, 1.6%)
Emergency CV sx (1, 0.8%)
Hemothorax (4, 3.2%)
IC hemorrhage, embolic stroke (3, 3.2%)
Vascular complication (1, 0.8%)
Acute embolization, (1, 2.3%)
Wire entrapment (1, 2.3%)
Iliac dissection (1, 2.3%)
• Summary: 1.4-2% death, 0.7-2% emergent cardiac surgery, 0.7-2% accessrelated complications, 2.5% hemothorax (transapical), 0.7-4% device-related
complications, 3.5-5% interference with prosthetic valve
ISACHD Congenital Heart Disease Basic Course
Case Follow-up: 6mo
• Patient at NYHA I, able to ride bike 6 miles
•
without limitation
No further transfusion requirements
• Labs:
• Hemoglobin 11.4 g/dL, NT proBNP 1466
pg/mL, LDH 594 U/l, INR 2.4, total bilirubin
0.8 mg/dL
ISACHD Congenital Heart Disease Basic Course
Case Follow-up: 6mo TTE