Successful transcatheter closure of paravalvular leak using unconventional supra-aortic vertebral catheters

Paravalvular regurgitation affects 5% to 17% of all surgically implanted prosthetic heart valves. Patients who have paravalvular regurgitation can be asymptomatic or present with hemolysis or heart failure, or both. Reoperation is associated with increased morbidity and is not always successful because of underlying tissue friability, inflammation, or calcification.

We suggest using supraaortic cathters for paravalvular leak closures. 61 year old female with hemolytic anemia, mechanical mitral valve (2004) and aortic valve replacement (2014) was referred with severe NYHC IV symptoms that progressively worsened over the past 12 months after AVR. She was found to have mutiple aortic perivalvular leaks at LCC and NCClocations, amounting to moderate to severe AR with VC of 0.5 & .7 cm respectively which was confirmed by TEE.

Angiography

Patient underwent aortogram & RHC, which confirmed the hemodynamic significance of the leak. Wedge pressure was 20 mmhg with a 35 mmhg v wave. We decided to proceed with Amplatz - AVP 4 closure of the two perivalvular leaks . The patient underwent general anesthesia and endotracheal intubation for transesophageal echocardiography (TEE) evaluation in the cardiac catheterization laboratory.

Procedure

A 6 French AL2 guide catheter was positioned within the aortic root and a Amplatz stiff wire advanced through the left paravalvular leak under fluoroscopic guidance. Multiple attempts were made to advance the 6 fr guide catheter, shuttle sheath and 6 fr MPA catheter. We finally used supraaortic 6 Fr VERT catheter, which was advanced into the LV. AVP 4 was deployed under flouroscopy & TEE guidance

Conclusion

Conventionally used for carotid and other supraaortic interventions,the unique angle of HY1 & VERT catheter make the ideal interventional tool for crossing small narrow paravalvular leaks. The obtuse primary angle gives it maneuverability to position AVP inside the paravalvular aperture. After AVP 4 deployment in the two PV leaks which resolved, patient had significant improvement in symptoms.