Transcatheter closure of multiple paravalvular leaks by a transapical approach under echocardiographic guidance: A case report

Case summary A patient who underwent mechanical aortic and mitral valve replacement developed three paravalvular leaks 10 months later. We located the tracks by puncturing the apex cordis under transoesophageal echocardiography guidance alone and puncturing the femoral artery guided by fluoroscopy. Three paravalvular leaks were occluded with a hybridization method simultaneously. The patient was followed up for 24 months and maintained a good condition. Conclusion Multiple paravalvular leaks after double valve replacement can be occluded in patients by the use of different approaches under echocardiographic guidance alone.

Transapical ultrasound-guided myectomy in midventricular obstructive hypertrophic cardiomyopathy

In patients with midventricular obstructive hypertrophic cardiomyopathy (HCM), a transapical approach allows excellent exposure for midventricular myectomy. Although the ventriculotomy is required on the antero-lateral left ventricular wall, the minimal ventriculotomy would be ideal, especially for cases with concomitant apical aneurysm. We report a case of midventricular obstructive HCM with concomitant apical aneurysm. Through the minimal ventriculotomy within the aneurysm, the hypertrophic septum was successfully hollowed out under repeated ultrasound guidance. Intraoperative ultrasound guidance is useful for transapical septal myectomy in midventricular obstructive HCM.

STABILISE Technique via a Transapical Approach to Repair Residual Type A Aortic Dissection

The stent-assisted balloon-induced intimal disruption and relamination in aortic dissection or STABILISE concept is a novel endovascular strategy in Type A and Type B dissections. We report a case of Type A aortic dissection repair combining, first, an open thoracic aortic surgery with an elephant trunk procedure and, second, an endovascular treatment using the STABILISE technique via a combined transapical approach commonly used for transcatheter aortic valve implantation and a femoral pathway.

Percutaneous Transapical approach in the Treatment of Paravalvular Leak

Background: Paravalvular leaks (PVLs) occur in up to 17% of patients after valve replacement. Due to the high morbidity and mortality associated with re-operation, percutaneous transapical (TA) closure has been introduced as an alternative to the surgical repair and percutaneous transcatheter closure in the treatment of PVLs. Here, we evaluated the outcomes of patients who underwent TA-closure for PVLs at the our centre.Methods: This study analyzed records of 12 patients with 13 problematic mechanical valves who underwent treatment at our hospital from April 2015 to November 2018. All procedures were performed under general anesthesia, with preoperative CT reconstruction and guidance by three-dimensional transesophageal echocardiography (3D-TEE). Results: Our data showed that all the TA punctures were successful with delivery sheath sizes that ranged from 5-7 Fr. Out of the 13 valves, 10 were single leaks (76.9%) and were all closed by a single occluder. There were 2 double leaks (15.3%) which were closed by two single bigger devices, while the remaining double leak was corrected by two separate devices. The median duration of the procedure was 82 minutes (IQR, 65-85 minutes). In addition, the mean postoperative ICU stay was 4 days (IQR, 1-2 days) and mean duration from procedure to hospital discharge was 7 days (IQR, 4-7 days). One patient died prior to the discharge. Conclusion: Taken together, our data demonstrates that percutaneous TA is safe and is associated with a low complication rate and procedure-related mortality. Multiple leaks and diameter of ≥ 10 mm might increase the risk for residual regurgitation.

Percutaneous mitral valve prostheses: 2019 update

During the last few years, there has been significant advances in the treatment of patients with severe mitral incompetence either too high risk for surgery or inoperable, this because of the improvements in percutaneous mitral valve prostheses, as alternative to the transcatheter mitral repair techniques. Percutaneous mitral valve replacement offers several advantages over the repair techniques, such as the opportunity to treat mitral valve with different anatomic characteristics, even the more complex ones, and the occasion to correct completely mitral regurgitation. The development of such prostheses has been a long process, still on the making. During the initial stages of the procedure, the transapical approach was preferred. On the other hand, the transseptal approach, which has already been used in some patients, is the proper development path for this transcatheter technique. Many valvular prostheses have been produced, each using a different mechanism for secure anchoring and elimination of regurgitation. Early mortality for this procedure, although decreasing since the preliminary studies, is still high, not only because the technology is still in its initial phase but also for the very high risk of the patients treated. It is foreseeable, though, that in the near future, as the technology and patients selection improves, better results will follow.