Ann Thorac Surg 2009;88:1327-1329. doi:10.1016/j.athoracsur.2009.02.054
© 2009 The Society of Thoracic Surgeons
Case Reports
Failure of Percutaneous Closure of Prosthetic, Aortic Paravalvular Leak
Evaristo Castedo, MD*,
Santiago Serrano-Fiz, MD,
Juan F. Oteo, MD,
Sebastian Ramis, MD,
Paloma Martinez, MD,
Juan Ugarte, MD
Department of Cardiothoracic Surgery, Hospital Universitario Puerta de Hierro Majadahonda, Universidad Autonoma de Madrid, Madrid, Spain
Accepted for publication February 17, 2009.
* Address correspondence to Dr Castedo, Department of Cardiothoracic Surgery, Hospital Universitario Puerta de Hierro Majadahonda, Manuel de Falla 1, Majadahonda, 28222, Spain (Email: evaristocm{at}terra.es).
 |
Abstract
|
|---|
We report the progression of aortic insufficiency after percutaneous closure of an aortic prosthesis paravalvular leak with the Amplatzer vascular plug (AGA Inc, Golden Valley, MN). Removal of the device and replacement of the aortic prosthesis was successfully performed. Based on operative findings, we hypothesize that shape mismatch between the occluder system and the leak might promote tearing at the end of slanted defects further enhancing the regurgitant area.
|
Introduction
|
|---|
Paraprosthetic leak is a relatively common complication after heart valve replacement. Redoing the operation in these cases is a difficult procedure with significant associated morbidity and mortality. Transcatheter closure has recently emerged as a promising alternative to open heart surgery. However, although complete leak correction can be achieved, the outcome of a percutaneous method is varied and complications such as device embolization, valve obstruction, arrhythmias, and thromboembolism have been reported [1, 2].
A 79-year-old man was referred to our department from a foreign institution with an aortic paraprosthetic leak. Six years ago he had undergone Hancock II aortic valve replacement for aortic stenosis and insufficiency. The aortic root and annulus were reported to be hugely calcified at the time of surgery. A paravalvular leak that caused moderate aortic regurgitation was detected in the early postoperative period, but as the patient was asymptomatic he was discharged and followed-up. Five years later, he presented with dyspnea and the aortic insufficiency had progressed to severity, pressure half-time was less than 200 msec, and the regurgitant jet area and left ventricular outflow tract area was 50%. An attempt at percutaneous transcatheter closure was then recommended. The device selected was a self-expandable nitinol 16-mm Amplatzer vascular plug (AGA Inc, Golden Valley, MN) that was successfully implanted in the leak. Transesophageal echocardiogram soon after deployment showed only a tiny residual leak, but a pre-discharge transthoracic echocardiography revealed that the aortic regurgitation had progressed; the regurgitant jet area and left ventricular outflow tract area was then 80%, and diastolic reversal of flow in the descending thoracic aorta was detected by color flow Doppler. In view of these findings, the patient was submitted for open heart surgery.
On admission to our hospital, the patient was symptomatic for recurrent dyspnea and hemolytic anaemia. He was operated on under standard cardiopulmonary bypass. Access to the valve was complicated due to a porcelain aorta, but a slant-eyed leak was observed just beneath the right coronary sinus (Fig 1A). The occluder device was correctly positioned within the leak cavity, but the dehiscence had progressed through the commissure between the left and right coronary sinus and half of the defect was actually not excluded (Fig 1B). The device was easily taken out (Fig 1C) and the bioprosthesis was replaced with a 21-mm St. Jude Medical mechanical valve (St. Jude Medical, Minneapolis, MN). The decision to implant a mechanical valve was based on the surgeon's preference in cases of porcelain aorta to facilitate the aortic closure. The postoperative course was uneventful. The patient was discharged 7 days later in good hemodynamic condition, with no residual leak on the echocardiography.
View larger version (109K):
[in this window]
[in a new window]
|
Fig 1. (A) Intraoperative photograph showing partial detachment of the bioprosthesis (in mosquito) beneath the right coronary sinus. The Amplatzer vascular plug (AGA Inc, Golden Valley, MN) is well positioned within the leak. (B) The tear is progressing through the commissure with the left coronary sinus (arrow). Shape mismatch between the slant-eyed defect and the cylindrical occluder device. (C) The Amplatzer (AGA Inc) (in forceps) being removed.
|
|
|
Comment
|
|---|
Despite evolving technology, the percutaneous management of paraprosthetic leaks is far from ideal nowadays. The reported series of the most experienced teams include only a few mitral procedures, and publications describing aortic leaks are rare [1]. The main reason is the current lack of a dedicated closure system. For example, one of the most widely used closure systems in the aortic position, the Amplatzer vascular plug (AGA Inc), was approved by the United States Food and Drug Administration for the occlusion of peripheral vessels [3]. The perfect fit of the occluder device within the leak cavity seems to be a major factor of success. Unfortunately, most dehiscences between the sewing ring and aortic annulus have an irregular crescent shape, and none of the available devices perfectly fit the leak defect. A cylinder-shaped device, such as the Amplatzer vascular plug may not only imperfectly occlude a slant-eyed leak, but may also promote tearing at both ends of the dehiscence while being deployed, further increasing the degree of regurgitation. This seems to be the case in our patient, in whom the aortic regurgitation jet width increased soon after the percutaneous closure attempt and a rip was observed through the left coronary sinus commissure. We should also be concerned about the surprisingly easy removal of the device and the possibility of dislodgement and catastrophic embolization. A dedicated device based on leak morphology assessed by previous operative findings is necessary to enhance the likelihood of success and should reduce the incidence of recurrent valve regurgitation and the need for reoperation.
|
References
|
|---|
- Pate Ge, Al Zubaidi A, Chandavimol M, Thompson CR, Munt BI, Webb JG. Percutaneous closure of prosthetic paravalvular leaks: case series and review Catheter Cardiovasc Interv 2006;68:528-533.[Medline]
- Aranzulla TC, Cosgrave J, La Canna G, et al. Percutaneous treatment of periprosthetic mitral valve leaks: is it just a futile exercise? Ann Thorac Surg 2008;86:996-998.[Abstract/Free Full Text]
- Hill SL, Hijazi ZM, Hellenbrand WE, Cheatham JP. Evaluation of the Amplatzer vascular plug for embolization of peripheral vascular malformations associated with congenital heart disease Catheter Cardiovasc Interv 2006;67:113-119.[Medline]
Top
Abstract
Introduction
