Closure of a Paravalvular Leak With Real-Time Three-Dimensional Transesophageal Echocardiography for Accurate Sizing and Guiding

ABSTRACT: Although closure of paravalvular leaks with Amplatzer occluders has been described in patients with increased perioperative risk, beneficial outcomes have not been consistently reported. Recent reports have described real-time three-dimensional transesophageal echocardiography (3D TEE) for facilitated guidance of the closure procedure. However, they did not focus on the critical issue of defect sizing. We report a case in which 3D TEE with off-line analysis of images to generate en face views of the mitral valve dehiscence allowed a simplified interrogation and definition of defect dimensions. 3D TEE was used for selection of the device size. The improved sizing was an important means to prevent device embolization as well as secure complete defect closure. Surprises with regard to the device size or the ability to anchor the device in a stable position were reduced.

J INVASIVE CARDIOL 2013;25(11):E210-E211

Key words: paravalvular leak, transesophageal echocardiography

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Although closure of paravalvular leaks with Amplatzer occluders after surgical valve replacement has been described in patients with increased perioperative risk, beneficial outcomes have not been consistently reported.^1,2 Two-dimensional (2D) TEE has been shown to complement fluoroscopy for catheter-based closure, but it has technical limitations, in particular to identify the location and extent of the leak and to determine the spacial relationship of the intracardiac catheter to the paravalvular defect. 

Real-time 3D TEE has been described for facilitated guidance of the closure procedure.³ However, recent publications did not focus on the sizing of the defect although it is a critical issue to prevent device embolization and secure complete closure of the defect. We present a case in which 3D TEE with off-line analysis was used for selection of the device size.

Case Report. A 52-year-old male with a 27 mm mechanical mitral valve replacement (St Jude Medical) and redo operation for paravalvular leakage developed increasing dyspnea (New York Heart Association class III), enlargement of the left ventricle (left ventricular end diastolic diameter, 64 mm), and impairment of left ventricular function (ejection fraction, 45%). Transesophageal echocardiography (TEE) revealed recurrent severe paravalvular leakage due to a dehiscence around the medial aspect of the sewing ring. Invasive pressure measurements revealed secondary pulmonary hypertension with a mean pulmonary artery pressure of 45 mm Hg. Repeat open-heart surgery was considered to require complete replacement of the mechanical valve with substantial risks even in this young patient. Real-time three-dimensional (3D) TEE (iE 33 [Philips Medical Systems] with an X7-2t TEE probe) allowed exact location of the leakage and sizing, indicating a defect size of 5.4 x 11 mm (Figures 1 and 2). The vena contracta area defined by 3D color Doppler was found to be 0.47 cm2. Thus, interventional closure of the defect was considered to be possible. After transseptal puncture in the basal area of the septum, an 8.5 Agilis NXT medium-curve steerable sheath was advanced across the septum with its tip positioned near the defect. A 5 Fr JR coronary catheter was telescoped within the Agilis sheath for additional steering capacity. Under guidance of real-time 3D TEE, the coronary catheter could be advanced close to the defect. Subsequently, an angled 260 cm Terumo Glidewire allowed crossing the defect (Figure 3). The coronary catheter was advanced into the left ventricle over the wire. The wire was exchanged for a 260 cm Amplatzer extra-stiff wire. This wire gave enough support to advance a 9 Fr guiding catheter through the paravalvular defect. A 14 x 5 mm Amplatzer Vascular Plug III (St Jude Medical) was advanced through the 9 Fr guiding catheter and sandwiched the defect effectively. 3D TEE confirmed the stability of the device, complete closure of the defect (Figure 4), adequate movement of both discs of the mitral valve prosthesis, and almost complete reduction of mitral regurgitation. 

Discussion. The ability of 3D TEE with off-line analysis to generate en face views of the mitral valve dehiscence allowed a simplified interrogation of defect dimensions in our patient. Surprises with regard to the device size or the ability to anchor the device in a stable position were reduced. The dimensions of the defect were analysed using two modalities of 3D TEE: (1) zoom mode; and (2) full-volume wide-angle acquisition with color Doppler allowing analysis of the vena contracta of the defect (Figures 1 and 2). Analysis was done off-line with commercially available software (3DQ, QLAB-Version 7.0, Philips Medical Systems). 

In this case, real-time 3D TEE allowed improved planning and guidance of the procedure and was a critical element for the success with regard to the following steps: 

1. Preprocedural analysis of the defect position and size allowing definition of procedural success probability and selection of the device size for closure of the defect. 
2. Puncture of the interatrial septum in the superior area allowing easier access to the defect located in the medial aspect of the sewing ring.
3. Guidance of the Agilis sheet as well as the coronary catheter to the proximity of the defect as well as subsequent guidance of the wire through the defect.
4. Confirmation of device stability within the defect. 

Conclusion. In summary, real-time 3D TEE adds significantly to 2D TEE and fluoroscopy in the catheter-based closure of paravalvular defects improving patient selection and safety as well as efficacy of procedural guidance.

References

1. Ruiz CE, Jelnin V, Kronzon I, et al. Clinical outcomes in patients undergoing percutaneous closure of periprosthetic paravalvular leaks. J Am Coll Cardiol. 2011;58(21):2210-2217. 
2. Alfirevic A, Koch CG. Failed closure of paravalvular leak with an Amplatzer occluder device after mitral valve replacement. Anesth Analg. 2009;108(2):439-440.
3. Azran MS, Romig CB, Locke A, Whitley WS. Application of real-time 3-dimensional transesophageal echocardiography in the percutaneous closure of a mitral paravalvular leak. Anesth Analg. 2010;110(6):1581-1583.

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From the Medical Clinic I, University Aachen, Aachen, Germany.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure
of Potential Conflicts of Interest. The authors report no conflicts of interest
regarding the content herein.

Manuscript submitted May 30, 2013, provisional acceptance given June 24,
2013, final version accepted July 8, 2013.

Address for correspondence: Rainer Hoffmann, MD, Medical Clinic I, University
RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany. Email:
RHoffmann@UKAACHEN.de