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Percutaneous Closure of Aortic Prosthetic Paravalvular Regurgitation with Two Amplatzer Septal Occluders

Phillips, Scott A. MD*; Thompson, Annemarie MD†‡; Abu-Halimah, Ahmad MD*; Crenshaw, Marshall H. MD*; Zhao, David X. MD*; Pretorius, Mias MD†‡

doi: 10.1213/ane.0b013e31818fbddc
Cardiovascular Anesthesiology: Echo Rounds
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From the *Division of Cardiology; †Department of Medicine; and ‡Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee.

This article has supplementary material on the Web site:www.anesthesia-analgesia.org.

Accepted for publication August 5, 2008.

None of the authors has a conflict of interest.

Address correspondence and reprint requests to Mias Pretorius, MBChB, MSc, 560 RRB, Vanderbilt University Medical Center, Nashville, TN 37232. Address e-mail to mias.pretorius@vanderbilt.edu.

We report the transesophageal echocardiography (TEE) findings of percutaneous closure of an aortic paravalvular defect with two Amplatzer septal occluder devices (AGA Medical Corporation, Plymouth, MN). The patient was an 82-year-old male who underwent an aortic valve replacement with a Mosaic bioprosthetic valve 5 mo before admission. He presented with increasing shortness of breath, and transthoracic echocardiography revealed partial dehiscence of the aortic bioprosthetic valve with severe paravalvular regurgitation. Because the patient failed medical therapy and repeat aortic valve surgery, which is associated with significant morbidity, the patient opted for percutaneous closure of the paravalvular defect.

The patient underwent general endotracheal anesthesia to facilitate TEE examination. Intraoperative TEE revealed severe paravalvular aortic regurgitation (vena contracta measured >6 mm) adjacent to the noncoronary sinus of Valsalva. (Fig. 1, and Video 1; please see video clips available at www.anesthesia-analgesia.org). After vascular access was obtained through the femoral artery, the patient was anticoagulated with heparin to maintain an activated clotting time more than 300 s. A guidewire was advanced under TEE and fluoroscopy guidance across the paravalvular defect into the left ventricle. A balloon was then advanced over the wire across the paravalvular defect and inflated. Because the TEE and aortogram demonstrated significant residual paravalvular regurgitation with one balloon inflated, a second balloon was placed across the paravalvular defect. Color Doppler TEE of the defect revealed a decrease in the paravalvular regurgitation. Right coronary artery angiography demonstrated adequate distance of the inflated balloons from the take-off of the right coronary artery. The balloons were deflated and removed over wires. An Amplatzer delivery device was advanced over the first wire, and an Amplatzer septal occluder was advanced through the delivery system. A second Amplatzer septal occluder was advanced through a separate delivery system. The distal disk of the Amplatzer septal occluder was first deployed in the left ventricle cavity and pulled back until resistance was felt. The proximal disk of the Amplatzer septal occluder was then deployed. This procedure was repeated with the second Amplatzer septal occluder. Both opened Amplatzer septal occluders were positioned across the defect, and TEE verified no interference of prosthetic leaflet motion. The best TEE view to assess the positioning of the Amplatzer septal occluders was obtained with a modified aortic valve long-axis view with slight clockwise rotation of the probe to reveal the noncoronary sinus of Valsalva. A gentle “to and fro” motion with the Amplatzer delivery cables assured a secure position of the opened Amplatzer septal occluders across the paravalvular defect (Fig. 2, and Video 2; please see video clips available at www.anesthesia-analgesia.org). Deployment (release of the delivery cables) occurred only after TEE confirmed adequate positioning of both septal occluders. The severity of the paravalvular regurgitation decreased to mild as assessed by color Doppler flow and no further intervention was deemed necessary. Adequate deep gastric aortic valve views were not obtainable to assess the severity of aortic regurgitation by pressure half-time or to calculate the pressure gradient across the bioprosthetic aortic valve after device deployment. The patient tolerated the procedure well and was discharged from the hospital on postoperative day 2. His shortness of breath improved and follow-up transthoracic echocardiography demonstrated only mild paravalvular aortic regurgitation with a mean pressure gradient of 20 mm Hg that was within the acceptable limits of this bioprosthetic valve.

Figure 1

Figure 1

Figure 2

Figure 2

Significant paravalvular regurgitation occurs in 1% to 5% of patients after valve replacement and is more common with mechanical than with bioprosthetic valves. Patients can present with hemolysis (associated with small defect <3 mm), heart failure (associated with large defect >6 mm) and arrhythmias. Although several different devices have been used to close paravalvular defects, there is no specific device designed for this purpose.1,2 The Amplatzer septal occluder is a percutaneous, transcatheter, closure device intended for the occlusion of secundum atrial septal defects and has been used off-label for percutaneous closure of both mitral and aortic valve paravalvular defects.2,3 Contraindications to percutaneous closure of paravalvular defects include mechanical instability of the prosthetic valve, intracardiac thrombus and evidence of local or systemic infection.2 In this case report, two Amplatzer septal occluders were used to close the paravalvular defect. Using more than one device potentially increases the risk of device dislodgement with embolization, interference with prosthetic leaflet motion resulting in valve stenosis and disruption of the prosthetic valve. TEE played a critical role in the percutaneous closure of this prosthetic aortic valve paravalvular defect because it helped to: 1) quantify the severity and location of the paravalvular defect, 2) facilitate placement of the guidewires across the paravalvular defect, 3) confirm adequate seating of the device across the defect before deployment, 4) verify normal prosthetic valve leaflet motion, and 5) assess severity of any residual paravalvular regurgitation after device deployment.

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REFERENCES

1. Webb JG, Pate GE, Munt BI. Percutaneous closure of an aortic prosthetic paravalvular leak with an Amplatzer duct occluder. Catheter Cardiovasc Interv 2005;65:69–72
2. Bhindi R, Bull S, Schrale RG, Wilson N, Ormerod OJ. Surgery insight: percutaneous treatment of prosthetic paravalvular leaks. Nat Clin Pract Cardiovasc Med 2008;5:140–7
3. Hein R, Lang K, Wunderlich N, Wilson N, Sievert H. Percutaneous closure of paravalvular leaks. J Interv Cardiol 2006;19(s5):S73–7
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