Multimodality Imaging Is Key for a Successful Paravalvular Leak Repair

Paravalvular leaks (PVL) are seen in 5-17% of patients after surgical mitral and aortic valve replacement. This is usually well-tolerated in the majority of patients; however, up to 5% will require re-intervention due to either hemodynamically significant regurgitation or hemolysis requiring repeated blood transfusion. Transcatheter closure of PVLs is becoming the treatment of choice in many patients owing to the high risk of redo surgery, high rates of recurrence with the surgical approach, and substantial improvements in device technology and growing expertise in structural heart disease interventions. Careful selection of the appropriate candidates by the Heart Team with in-depth analysis of clinical and multimodality imaging data is critical to ensuring good short- and long-term outcomes.The defect is usually oval/ crescentic and often serpiginous in nature, which poses significant challenges in the optimal size and number of devices to implant - especially with large size defects. Generally, defects involving more than 25-30% of the sewing ring are generally deemed unsuitable for percutaneous closure. While the Amplatzer family of vascular plugs (e.g. AVP3 and AVP2) is commonly used for percutaneous closure of PVLs, there are currently no approved dedicated devices for this indication, except the paravalvular leak device (Occlutech) which is not universally available. Small and relatively circular defects can usually be closed using a single plug, conventionally utilizing a size that is 25-30% larger than the mean diameter of the defect. Larger and crescentic defects on the other hand frequently require more than one plug and can be quite challenging in terms of choosing the appropriate size(s).We report two cases with very large defects with irregular shape in which 3D printed modeling was extremely useful for bench testing to optimize the number and sizes of devices to be implanted.

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Challenging Cases of Aortic Prosthesis Dysfunction, the Importance of Multimodality Imaging, a Case Series

Diagnostics ◽

10.3390/diagnostics11122305 ◽

2021 ◽

Vol 11 (12) ◽

pp. 2305

Author(s):

Valeria Pergola ◽

Giulio Cabrelle ◽

Giorgio De Conti ◽

Giulio Barbiero ◽

Donato Mele ◽

...

Keyword(s):

Multimodality Imaging ◽

Correct Diagnosis ◽

Case Series ◽

Paravalvular Leak ◽

Complementary Technique ◽

Aortic Prosthesis ◽

Prosthetic Aortic Valve ◽

Subaortic Membrane ◽

Aortic Valve Implantation ◽

Valve Implantation

ECG-gated multidetector computed tomography (MDCT) is a promising complementary technique for evaluation of cardiac native and prosthetic structures. MDCT is able to provide a broader coverage with faster scan acquisition times that yield higher spatial and temporal resolution for cardiac structures whose quality may be affected by artifacts on ultrasound. We report a case series about the most challenging complications occurring after prosthetic aortic valve implantation in four patients: pannus, paravalvular leak, prosthesis’ misfolding and subaortic membrane reformation. In all the cases, enhanced MDCT using a retrospective protocol provided accurate 3D morphoanatomic information about cardiac and extracardiac structures, improving and speeding up the correct diagnosis and treatment planning. Integrated imaging, in particular with MDCT, is now the present, and it will increasingly be the future in the assessment of cardiac structural pathology.

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Pre-interventional assessment and calcification score of the aortic valve and annulus, with multi-detector CT, in transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve

South African Journal of Radiology ◽

10.4102/sajr.v19i1.762 ◽

2015 ◽

Vol 19 (1) ◽

Author(s):

Antoinette Reinders ◽

Coert S. De Vries ◽

G. Joubert

Keyword(s):

Computed Tomography ◽

Aortic Valve ◽

Transcatheter Aortic Valve Implantation ◽

Scoring System ◽

Multimodality Imaging ◽

Final Analysis ◽

Paravalvular Leak ◽

Transcatheter Aortic Valve ◽

Aortic Valve Implantation ◽

Valve Implantation

Background: Transcatheter aortic valve implantation (TAVI) provides an acceptable alternative for aortic valve replacement in the elderly, but needs accurate pre-procedural imaging to optimise intervention. Objectives: To evaluate an alternative manual aortic valve calcification scoring system with computed tomography, for patients undergoing TAVI. We hypothesise a correlation between the Free State aortic valve calcium computed tomography score (FACTS) scoring system, valve plaque density and procedure-related complications. Methods: Twenty patients suitable for TAVI were selected according to standard international guidelines and received multimodality imaging prior to intervention. Images were reviewed by two reviewers who were blinded to each other’s scores. Where large inter-individual score variations existed, retraining was done and scores repeated, using a double-blinded method. Matched scores were included in the final analysis. Rosenhek calcification scores were used as a standard of reference. Results: The study comprised 9 (45%) men and 11 (55%) women, with a median age of 83.5 years. Median EuroSCORE was 15.5. FACTS scores ≥6 were associated with the presence of a paravalvular leak (p = 0.01). Procedure-related complications (left bundle branch block, repositioning of the valve and anaemia) were seen in patients with plaques measuring ≥1000 HU (p = 0.07). Conclusion: The FACTS score and averaged valve plaque HU showed potential for predicting a paravalvular leak and procedure-related complications, and could be valuable in the future for optimising patient selection for TAVI.

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P1780Usefulness of multimodality imaging approach in the diagnosis of mechanical prosthetic valve dysfunction

European Heart Journal ◽

10.1093/eurheartj/ehz748.0532 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

L Fusini ◽

M Muratori ◽

G Teruzzi ◽

S Ghulam Ali ◽

E Innocenti ◽

...

Keyword(s):

Diagnostic Accuracy ◽

Predictive Value ◽

Prosthetic Valve ◽

Multimodality Imaging ◽

Imaging Modality ◽

Paravalvular Leak ◽

High Morbidity ◽

Combined Model ◽

Long Term Outcome ◽

Imaging Approach

Abstract Background Although the long-term outcome of mechanical mitral and aortic prosthetic valve (M-PV, Ao-PV), PV dysfunction (PVD) remains a very serious complication associated with high morbidity and mortality. Thrombosis/pannus and paravalvular leak are the 2 main mechanisms of PVD. The diagnosis of PVD, based on clinical presentation may be challenging, but it is essential for referring the patient to the optimal treatment (clinical follow-up, thrombolysis, surgery). An integrated multimodality imaging approach, comprising several parameters by transthoracic echocardiography (TTE) and fluoroscopy (F), is mandatory to pursue the correct therapeutic pathway. Purpose This study aims to evaluate the incremental diagnostic value of combined TTE+F over each imaging modality alone in symptomatic pts with Ao-PV or M-PV and high suspicion of PVD. Methods 387 consecutive pts (63±11y, 213 Ao-PV, 173 M-PV) suspected for PVD, symptomatic for dyspnea, embolic events, fever or haemolysis were enrolled. All patients were imaged by TTE and F within 2 days after the admission to the hospital. TTE was defined positive for PVD in presence of intra/para-prosthetic regurgitation or high transprosthetic gradient (>20mmHg in Ao-PV, >8mmHg in M-PV) together with altered Doppler parameters (for Ao-PV: DVI <0.25, AT>95ms; for M-PV: Peak Mitral Velocity>2m/sec, VTIPrMV/VTILVO>2.5, PHT>130ms). F was defined positive for PVD when leaflet/s restriction occurs. PVD was confirmed by transoesophageal echocardiography (TOE) or positive response of thrombolysis (T), or surgical inspection (S). Results PVD was found in 46% (99/213) of Ao-PV and in 53% (91/173) of M-PV at TOE/T/S. Sensitivity (SE), specificity (SP), negative predictive value (NPV), positive predictive value (PPV) and diagnostic accuracy (ACC) for TTE, F and combined TTE+F are reported in Table. The integration of TTE+F data significantly improved ACC both for Ao-PV and M-PV. At ROC analysis, the combined model of TTE+F showed the highest AUC for the detection of PVD compared with TTE and F alone (Figure). Table 1. Comparison of diagnostic accuracy between TTE, F, and TTE+F TTE-Ao-PV (n=211) F-Ao_PV (n=204) TTE+F-Ao-PV (n=202) TTE-M-PV (n=172) F-M-PV (n=158) TTE+F-M-PV (n=157) SE / SP / NPV / PPV / ACC (%) 86 / 89 / 88 / 88 / 88 59 / 99 / 72 / 98 / 79 94 / 88 / 94 / 88 / 91 74 / 90 / 75 / 89 / 81 49 / 96 / 60 / 93 / 70 81 / 86 / 78 / 88 / 83 Figure 1. ROC curves Conclusions In patients with clinical suspicion of PVD, TTE and F are both valid tools to evaluate the PV performance. However, the combined model of TTE+F had a significant incremental value over TTE or F alone to diagnose the presence of PVD. This multimodality imaging approach allows to overcome several weaknesses of the TTE or F alone and consequently provides a prompt recognition of PVD even though TOE remains the gold standard to diagnose paravalvular Leak and non-obstructive thrombosis.

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P1476 Percutaneous paravalvular leak closure after transcatheter aortic valve replacement expedited with multimodality imaging

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jez319.901 ◽

2020 ◽

Vol 21 (Supplement_1) ◽

Author(s):

O Ozden Tok ◽

M Abdelnabi ◽

G Bingol ◽

A Almaghraby ◽

O Goktekin ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Transcatheter Aortic Valve Replacement ◽

Multimodality Imaging ◽

Imaging Modality ◽

Paravalvular Leak ◽

Integrated Analysis ◽

Aortic Valve Area ◽

Transcatheter Aortic Valve

Abstract A 75-year-old male admitted to our hospital with decompansated heart failure symptoms. He had a history of 3 vessel coronary artery bypass grafting 10 years ago and a 29 mm Evolut R bioprosthetic transcatheter aortic valve replacement (TAVR) history 2 months ago. His physical examination revealed a 3/6 diastolic murmur on the aortic valve area. We performed a transeosophagel echocardiography (TOE) as the transthoracic echocardiography (TTE) images were not so clear and didn’t guide enough for the procedure . TOE showed a severe paravalvular leak . After we found out from his medical reports that postprocedural ad-hoc post dilatation was performed but didn’t work, we decided to close this paravalvular leak percutanaously . According to TOE, the paravalvular leak was at 12 o’clock position. We identified the corresponding location of the leak on previous CT images which was scanned pre-TAVR for selection of the valve size and planning of the procedure. We recognized that the leak location was corresponding to a very calcified part of the aortic annulus and the reason of the severe PVL seemed to be due to this nodular extensive calcification. We planned the procedure according to TOE-CT integrated analysis and selected the optimal flouroscopic viewing angle.The defect was found and crossed in 20 seconds after the wire passed through arcus aorta.The selected VSD Occluder(No:12) was deployed precisely by extending the device throughout the defect. Succesful complete closure was confirmed with TOE. In the past 1o years, TAVR has become the treatment of choice for patients with severe aortic stenosis with a higher operative risk. Different studies have depicted a higher incidence of PVR in patients who undergo TAVR compared to SAVR. Percutaneous postTAVR PVL closure is a technically challenging procedure. Echocardiography remains the primary imaging modality for assessing PVR immediately following TAVR. Finding and crossing the PVL defect is one of the most difficult and time-consuming parts of the procedure. The reason of this difficulty can be different anatomies, bad quality imaging and lack of common language between interventional cardiologist and cardiac imaging expert. To facilitate this part of the procedure integration of echocardiograohy and CT and finding the best angulation for flouroscopy seems to be quite promising. Abstract P1476 Figure. Step by step approach to PostTAVR

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