Novel Antegrade Approach to Transcatheter Aortic Valve Paravalvular Leak Closure

J INVASIVE CARDIOL 2019;31(10):E306-E307.

Key words: aortography, paravalvular leak, PVL closure

Aortic paravalvular leak (PVL) is a known complication of transcatheter aortic valve replacement (TAVR). PVL closure using vascular occluder devices can be done, particularly in cases with annular calcification preventing adequate seal. In current practice, PVL closure is accomplished by retrograde wiring of the defect followed by delivery of catheters and retrograde extrusion of the device. Delivery of equipment can be challenging in TAVR because of interaction with the valve stent. We describe a novel antegrade closure approach to treat transcatheter aortic PVL.

Two patients who underwent TAVR using self-expanding CoreValve devices (Medtronic) presented with symptomatic severe aortic PVL (Figures 1A and 2A) secondary to annular calcification preventing adequate seal. We decided to proceed with PVL closure using vascular closure devices in the usual retrograde approach. A stiff-angled Glidewire (Terumo) was used to wire the defect through a 5 Fr multipurpose (MP) catheter in a 6 Fr guiding catheter. In both cases, the 5 Fr MP crossed the valve stent frame but not the guiding catheter due to interaction with the stent frame (Figures 1B and 2B). The Glidewire was switched to an extra-stiff wire via the 5 Fr MP for more support, and a shuttle sheath was used instead of the guide catheter, to no avail. We then switched again to a Glidewire through the 5 Fr MP into the left ventricle (LV) and advanced it back through the center of the aortic prosthetic valve and positioned it in the arch of the aorta. The Glidewire was snared using a snare device placed through a second femoral arterial access to create a rail. This again did not provide enough support to advance a guiding catheter retrograde across the valve stent. After that, a decision was made to attempt an antegrade approach. We advanced a shuttle sheath over the rail, through the transcatheter aortic prosthetic leaflets and antegrade across the defect (Figures 1C and 2C), followed by successful extrusion of the disks of the vascular closure devices across the defect, closing the PVL (Figures 1D, 1E, and 2D).

The antegrade approach to aortic PVL closure is a novel technique that is useful when there is resistance delivering equipment in a retrograde fashion across the transcatheter valve frame.

From the Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.

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. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted May 14, 2019.

Address for correspondence: Guy S. Reeder, MD, Mayo Clinic, 200 First St. SW, Rochester, MN 55905. Email: reeder.guy@mayo.edu