J INVASIVE CARDIOL 2017;29(2):E23-E25.
Key words: paravalvular leak, FluoroCT, software
A 71-year-old female was referred with New York Heart Association class III heart failure, mild hemolytic anemia, and a moderate to severe paravalvular leak (PVL) of a mechanical mitral prosthesis (25 mm; St. Jude Medical). She had cardiac surgery three times earlier due to a primum atrial septal defect (ASD), residual ASD, and mitral regurgitation. She had chronic atrial fibrillation with a DDD pacemaker and type 2 diabetes mellitus. Following a heart team discussion, she was set up for transcatheter PVL closure.
A multislice computed tomography (MSCT) was performed and analyzed using FluoroCT version 3.1 for OS X 10.11 (application published by P. Theriault-Lauzier). FluoroCT is a novel dedicated software for simulation of fluoroscopic anatomy using volumetric rendering.1,2 The mitral valve prosthesis was identified in the multiplanar reconstruction (MPR) mode and traced en face along with the PVL (Figure 1A). The PVL was localized at the anteroseptal margin of the mitral valve prosthesis in relation to the left ventricular outflow tract (LVOT) and the atrial septum (Figures 1A and 1C).
Simulated fluoroscopic images with the traced structures were derived by the software (Figures 1B and 1D). Exact angulations of the C-arms were used to obtain en face and perpendicular views of the mitral valve prosthesis (Figures 1B and 1D). In order to facilitate crossing of the PVL and allow visualization of valve leaflet function, the perpendicular angle was chosen so that the PVL was projected free of the mitral valve prosthesis at its superior margin without overlap.
The PVL closure was performed under general anesthesia with three-dimensional transesophageal echocardiography (TEE) and a biplane Siemens Artis Zee angiographic system. An antegrade transseptal approach was used, with a puncture in the mid-portion of the atrial septum. The derived C-arm angulations were set giving a direct en face view and a perpendicular view of the mitral valve prosthesis. An 8.5 Fr steerable guiding sheath (Oscor) with a 6 Fr multipurpose coronary guiding catheter and a 0.035˝ Terumo Glidewire inside was placed in the left atrium and curved toward the PVL (Figures 2A and 2D). The PVL was easily crossed in less than 5 minutes (Figures 2B, 2E, 3B) due to the known spatial fluoroscopic anatomy and the exact site of the PVL relative to the prosthesis. TEE and intravascular ultrasound showed a maximum PVL channel diameter of 8 mm. A 10 mm Amplatzer Vascular Plug II (St. Jude Medical) was successfully expanded within the PVL (Figures 2C, 2F, 3C, 3D). Position and concealment of the leak were confirmed by TEE (Figures 3C and 3D) without interference between the closure device and mitral valve leaflets or left ventricular outflow tract flow. Stable device position was confirmed by fluoroscopy the day after the procedure. The patient had early and marked improvement in symptoms upon discharge.
Three-dimensional TEE is essential in guiding PVL closure. This case demonstrates additional benefit of MSCT and preprocedural fluoroscopic simulation for interventional guidance of PVL closure. This technique allows definition of optimal C-arm angulations and localization of the PVL in reference to procedural fluoroscopic views. It was helpful for guidewire crossing of the PVL and positioning of the closure device and has the potential to improve procedural outcome, reduce procedure time, reduce fluoroscopy time, and minimize complications.
1. Thériault-Lauzier P, Andalib A, Martucci G, et al. Fluoroscopic anatomy of left-sided heart structures for transcatheter interventions: insight from multislice computed tomography. JACC Cardiovasc Interv. 2014;7:947-957.
2. Spaziano M, Thériault-Lauzier P, Meti N, et al. Optimal fluoroscopic viewing angles of left-sided heart structures in patients with aortic stenosis and mitral regurgitation based on multislice computed tomography. J Cardiovasc Comput Tomogr. 2016;10:162-172.
From the 1Department of Cardiology, Aarhus University Hospital, Skejby, Denmark; and 2McGill University Health Centre, Montreal, QC, Canada.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Piazza is co-founder of FluoroCT and a consultant for Medtronic. Dr Thériault-Lauzier is co-founder of FluoroCT and a consultant for Circle CVI and HighLife Medical. Dr Jensen reports speakers honoraria from Bracco Imaging. Dr Nielsen-Kudsk is a proctor for St. Jude Medical and Gore Medical. The remaining authors report no conflicts of interest regarding the content herein.
Manuscript submitted August 9, 2016, final version accepted August 15, 2016.
Address for correspondence: Jens Erik Nielsen-Kudsk, MD, DMSc, Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark. Email: email@example.com