Document downloaded from http://www.revespcardiol.org, day 07/10/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
`
`Scientific letters / Rev Esp Cardiol. 2015;68(11):1027–1038
`
`1035
`
`Paravalvular Leak Closure After Transcatheter
`Aortic Valve Implantation Simultaneously Using
`AmplatzerTM Vascular Plug III and IV Devices
`
`Cierre de fuga paravalvular tras implante percuta´neo
`de va´lvula ao´rtica usando simulta´neamente dispositivos
`AmplatzerTM Vascular Plug III y IV
`
`To the Editor,
`
`Significant paravalvular aortic regurgitation after transcath-
`eter aortic valve implantation (TAVI) is associated with poor
`short- and long-term prognosis.1,2 Experience with percutaneous
`closure of paravalvular leaks (PVLs) after TAVI is limited but the
`results are good.3 Currently, the most commonly used device is
`the AmplatzerTM Vascular Plug (AVP) IV (St. Jude Medical, St. Paul,
`Minneapolis, United Stated), mainly due to its shape and design
`and because it can be introduced via a 4 to 5-F diagnostic
`catheter.3 Although the AVP III is currently one of the most
`popular surgical prosthetic devices for percutaneous closure of
`PVLs, it has scarcely been used for the closure of PVLs after TAVI.3
`We report the first case, to our knowledge, of percutaneous
`closure of a PVL after aortic CoreValveW prosthesis implantation
`(Medtronic, Minneapolis, Minneapolis, United Stated) simulta-
`neously using AVP III and IV devices.
`We present the case of an 86-year-old woman with severe
`symptomatic aortic stenosis and high surgical risk (logistic
`EuroSCORE I of 22) who was transferred to our unit (after
`medical-surgical conference discussion) for TAVI implantation.
`After predilatation with a 22-mm NuCLEUSTM balloon (NuMED,
`Inc., Hopkinton, New York, United States), a 26-mm CoreValveW
`
`transfemoral prosthesis was implanted. The prosthesis was well
`positioned (maximum prosthetic penetration
`in the outflow
`tract of the
`left ventricle of 7 mm as measured by 2- and
`3-dimensional transesophageal echocardiography and angiogra-
`phy) but was not attached to the aortic ring at the posterior site,
`probably due
`to considerable
`focal calcification, although
`determination of the exact mechanism
`is difficult. Despite
`post-dilatation of the prosthesis with a 24-mm NuCLEUSTM
`balloon (the aortic ring diameter on echocardiography was 23 mm),
`significant paravalvular aortic regurgitation was observed in the
`final aortography (Figure 1A) It was decided to perform close
`echocardiographic and clinical follow-up and evaluate the possibili-
`ty of elective percutaneous closure of the PVL.
`However, 1 month after the procedure, the patient was
`admitted with congestive heart
`failure. Subsequent 2- and
`3-dimensional transesophageal echocardiography confirmed that
`a 9  4-mm-sized crescent-shaped PVL at the posterior site was
`causing severe paravalvular aortic regurgitation (Figures 1B-D).
`After further discussion, it was decided to perform percutane-
`ous closure of the PVL. The PVL was crossed using a 5-F Amplatz-
`Left-1 catheter (Medtronic) and a straight hydrophilic guide wire
`(Figure 2A). This guide wire was subsequently replaced with a
`(Amplatz Super StiffTM, Boston Scientific,
`stiff guide wide
`Marlborough, Massachusetts, United States). The delivery sheath
`(5-F AmplatzerTM TorqVueTM Delivery System, St. Jude Medical)
`was then advanced and an 8  4-mm AVP III device was deployed
`in the PVL (Figure 2B). Next, following the same procedure, an
`8-mm AVP IV device was implanted parallel to the previous device
`(Figure 2C), considerably reducing the paravalvular aortic regur-
`gitation (Figure 2D). After the procedure, the patient rapidly
`
`Figure 1. A: Significant paravalvular aortic regurgitation after implantation of a 26-mm aortic CoreValveW prosthesis, probably due to major focal calcification at the
`posterior site. B: 1808 transesophageal echocardiography showing paravalvular leak at the posterior site with severe paravalvular aortic regurgitation. C: 188 (short
`axis) transesophageal echocardiography showing a crescent-shaped paravalvular leak at the posterior site. D: Reconstruction and measurement of the paravalvular
`leak with 3-dimensional transesophageal echocardiography (9  4 mm). LA, left atrium.
`
`Page 1 of 2
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`Document downloaded from http://www.revespcardiol.org, day 07/10/2016. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
`
`1036
`
`Scientific letters / Rev Esp Cardiol. 2015;68(11):1027–1038
`
`Figure 2. A: A 5-F Amplatz-Left-1 catheter and straight hydrophilic guide wire crossing the paravalvular leak. B: Deployment of the 8  4-mm AmplatzerTM
`Vascular Plug III device (red asterisk). C: Deployment of the 8-mm AmplatzerTM Vascular Plug IV device (blue asterisk). D: 1808 transesophageal echocardiography
`showing markedly reduced aortic paravalvular regurgitation after implantation of the devices. LA, left atrium; LV, left ventricle.
`
`improved and was discharged after 48 hours. One month after the
`procedure, the patient was asymptomatic.
`This case reflects the
`importance of the assessment and
`treatment of post-TAVI PVL. Due to the huge
`irregularity
`and variability in the morphology of PVLs primarily caused by
`ring calcification, we believe that deployment and attachment of
`2 distinct devices, such as an AVP III and IV, to a single PVL could
`have advantages over the
`implantation of a single device.
`Moreover, the use of more than 1 device smaller than the leak
`allows the use of delivery sheaths with smaller calibers. To our
`knowledge, this is the first case of percutaneous closure of a PVL
`after aortic CoreValveW prosthesis implantation simultaneously
`using implantation of AVP III and IV devices.
`
`CONFLICTS OF INTEREST
`
`I. Cruz-Gonza´ lez is a proctor for St. Jude Medical.
`
`Ignacio Cruz-Gonza´ lez, Juan C. Rama-Merchan,*
`Javier Rodrı´guez-Collado, Fe´ lix Nieto-Ballestero,
`Antonio Arribas-Jime´ nez, and Pedro L. Sa´ nchez
`
`Departamento de Cardiologı´a, Hospital Clı´nico Universitario
`de Salamanca, IBSAL, Salamanca, Spain
`
`* Corresponding author:
`E-mail address: ramamerchan@hotmail.com (J.C. Rama-Merchan).
`
`Available online 6 October 2015
`
`REFERENCES
`
`1. Van Belle E, Juthier F, Susen S, Vincentelli A, Iung B, Dallongeville J, et al.
`Postprocedural aortic regurgitation in balloon-expandable and self-expandable
`transcatheter aortic valve replacement procedures: analysis of predictors and
`impact on long-term mortality: insights from the FRANCE2 Registry. Circulation.
`2014;129:1415–27.
`2. Sinning JM, Vasa-Nicotera M, Chin D, Hammerstingl C, Ghanem A, Bence J, et al.
`Evaluation and management of paravalvular aortic regurgitation after trans-
`catheter aortic valve replacement. J Am Coll Cardiol. 2013;62:11–20.
`3. Saia F, Martinez C, Gafoor S, Singh V, Ciuca C, Hofmann I, et al. Long-term
`outcomes of percutaneous paravalvular regurgitation closure after transcatheter
`aortic valve replacement: a multicenter experience. JACC Cardiovasc Interv.
`2015;8:681–8.
`
`http://dx.doi.org/10.1016/j.rec.2015.07.019
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