International Journal of Cardiology 198 (2015) 37–39
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Computed tomography guided percutaneous transapical closure of cardiac apex after prosthetic mitral paravalvular leak closure Cengiz Ozturk a,⁎, Atila Iyisoy a, Turgay Celik a, Sevket Balta a, Ugur Bozlar b, Mustafa Demir a, Ali Osman Yildirim a, Adem Guler c a b c
Gulhane Military Medical Academy, School of Medicine, Department of Cardiology, Etlik, Ankara, Turkey Gulhane Military Medical Academy, School of Medicine, Department of Radiology, Etlik, Ankara, Turkey Gulhane Military Medical Academy, School of Medicine, Department of Cardiovascular Surgery, Etlik, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 11 June 2015 Accepted 26 June 2015 Available online 2 July 2015
Dear Editor, The transapical transcatheter approach for percutaneous interventions is performed in high-risk patients with peripheral vascular disease and when transseptal attempt failed. The apical access is traditionally performed through a left minithoracotomy at the fifth intercostal space under general anesthesia. But, there are some complications and risks like ventricular arrhythmias, ventricular tear and life-threatening surgical bleeding in the apical access even though it is a minimally invasive procedure [1]. Although new apical closure devices have been developed and tested in animals and humans, the apical closure remains a challenge in recent studies [2]. The cardiologists started to use the occluders to close the percutaneous apical accesses [3–11]. We report a case of a successful percutaneous closure of the apical access with a 4 mm ADO-II device after a standard transapical mitral paravalvular leak closure procedure without minithoracotomy with the computed tomography guidance. This case is the second from Turkey, so the first one was published recently in this journal [12]. In this second case, we used the CT guidance for optimal puncture of cardiac apex. A 44 year old female was admitted to our department with severe dyspnea (NHYA classes II–III). She had hemolytic anemia (hemoglobin level 8.0 g/dL, lactate dehydrogenase level was high). She had a history of mitral metallic prosthesis valve replacement in 1994. Transesophageal echocardiography (TEE) showed two severe mitral paravalvular leaks (6 and 9 mm) of the mitral valve prosthesis. Transesophageal echocardiography (TEE) showed two severe mitral paravalvular leaks (6 and
⁎ Corresponding author at: Department of Cardiology, Gulhane School of Medicine, Tevfik Saglam St., 06018, Etlik, Ankara, Turkey. E-mail address: [email protected] (C. Ozturk).
http://dx.doi.org/10.1016/j.ijcard.2015.06.121 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Fig. 1. CT angiographic image of the patient marked with an arrow-1.
Fig. 2. CT angiographic image of the patient marked with an arrow-2.
38
Letter to the Editor
Fig. 3. Transapical approach with a needle externally.
Fig. 5. An AL-1 catheter is placed in the left atrium through the paravalvular mitral leak.
9 mm) of the mitral valve prosthesis. No active endocarditis was present. The patient was symptomatic because of two mitral paravalvular leaks and high risk for surgery. She had dyspnea during regular efforts. Firstly, we tried to close the leaks through the transseptal approach but we failed. We could not pass through the defects before. After that, we decided to try the transapical approach. Before the procedure, in order to obtain optimal puncture of the apical region of the left ventricle, a computed tomography was also performed. The radiologist marked the apex with an arrow at the sixth intercostal area and costochondral junction with left anterior 30° projection (Figs. 1, 2). Under general anesthesia, TEE, CT and fluoroscopic guidance, transapical cannulation of the left ventricle from the sixth intercostal area and midclavicular region with a needle was
performed and a 6 F sheath was inserted to the apical region. (Fig. 3). A Terumo hydrophilic wire was loaded on a right Judkins 6 F catheter and passed through the defects (Fig. 4). After the positioning of the catheter inside the left atrium (LA), the Terumo wire was replaced by an Amplatzer stiff wire. Then AL-1 guided the catheter to the LA (Figs. 5, 6). Through the guide catheter, a 10 mm × 5 mm Vascular Amplatzer plug was successfully deployed under 2D and 3D TEE and fluoroscopic imaging (Fig. 7). The two leaks were closured. TEE showed an appropriate position of the device and there was no residual mitral paravalvular leak after deployment. No complications were observed. After that, the placement of the myocardial occluder (4 mm ADO-II) (Figs. 8, 9) was performed through the delivery system, with a very small amount of blood
Fig. 4. A 0.38 inch guiding wire and a pigtail catheter are placed in the left atrium through the paravalvular mitral leak.
Fig. 6. A superstiff guiding wire is placed in the lower right pulmonary vein through the paravalvular mitral leak.
Letter to the Editor
Fig. 7. A delivery system and device are placed in the left atrium through the paravalvular mitral leak. Distal part of a vascular plug device is advanced through the delivery system.
loss and an acceptable sealing of the apical tear. There was also no scar on the chest wall. This approach with the computed tomography guidance can be done also easily and represents a further step to the routine percutaneous transapical heart valve procedures. The patient was discharged 6 days after the procedure in NYHA class I. The hemolytic indices also improved.
Conflict of interest There is no conflict of interest.
Fig. 8. Distal part of an ADO-II device is advanced through the delivery system to the apical region of the left ventricular apex.
39
Fig. 9. After leaving an ADO-II device in the apical region of the left ventricular apex.
References [1] L.K. von Segesser, G. Gerosa, M.A. Borger, E. Ferrari, Prevention and management of potential adverse events during transapical aortic valve replacement, J. Heart Valve Dis. 22 (2013) 276–286. [2] J. Blumenstein, J. Kempfert, A. Van Linden, et al., First-in-man evaluation of the transapical APICA ASCi access and closure device: the initial 10 patients, Eur. J. Cardiothorac. Surg. 44 (2013) 1057–1062. [3] H. Brinks, F. Nietlispach, V. Göber, et al., Transapical access closure: the TA PLUG device, Interact. Cardiovasc. Thorac. Surg. 17 (2013) 806–809. [4] Rajeev Fernando, David F. Briceno, Pranav Loyalka, Biswajit Kar, Transapical closure of mitral paravalvular leak over a surgically constructed mitral annulus, Int. J. Cardiol. 171 (2) (2014) 302–304, http://dx.doi.org/10.1016/j.ijcard.2013.11.072. [5] Saskia Pokorny, Katharina Huenges, Telse Bähr, Jan Hinnerk Hansen, Gunther Fischer, Justus Gross, Michael Morlock, Jochen Cremer, et al., Transapical mitral valved stent implantation: Enhanced survival and decreased paravalvular leakages, Int. J. Cardiol. 175 (3) (2014) 418–424, http://dx.doi.org/10.1016/j.ijcard.2014.11. 108. [6] Giuseppe Bruschi, Federico De Marco, Luca Botta, Alberto Barosi, Paola Colombo, Silvia Mauri, Aldo Cannata, Nuccia Morici, et al., Right anterior mini-thoracotomy direct aortic self-expanding trans-catheter aortic valve implantation: A single center experience, Int. J. Cardiol. 181 (2015) 437–442, http://dx.doi.org/10.1016/j.ijcard. 2014.11.108. [7] E. Ferrari, D. Locca, D. Berdajs, C. Marcucci, F. Gronchi, J. Lavanchy, R. Prêtre, P. Tozzi, Use of a ventricular septal defect occluder for apical closure in transapical aortic valve replacement, Innovations (Phila) 10 (1) (Jan–Feb 2015) 68–70, http://dx. doi.org/10.1097/IMI.0000000000000118. [8] J. Blumenstein, J. Kempfert, W. Kim, C. Liebetrau, H. Möllmann, T. Walther, Transapical access and closure devices: rationale and current status, Expert. Rev. Cardiovasc. Ther. 11 (12) (Dec 2013) 1613–1617, http://dx.doi.org/10.1586/ 14779072.2013.847788. [9] H. Brinks, F. Nietlispach, V. Göber, L. Englberger, P. Wenaweser, B. Meier, T. Carrel, C. Huber, Transapical access closure: the TA PLUG device, Interact. Cardiovasc. Thorac. Surg. 17 (5) (Nov 2013) 806–809, http://dx.doi.org/10.1093/icvts/ivt309 (discussion 809–10. Epub 2013 Jul 9). [10] L. Tang, Z. Fang, X. Hu, J. Tang, X. Shen, X. Lu, Y. Zhao, J. Li, S. Zhou, Non-surgical repair of ventricular septal rupture after acute myocardial infarction, Int. J. Cardiol. 185 (Mar 17 2015) 328–332, http://dx.doi.org/10.1016/j.ijcard.2015.03.144 (Epub ahead of print). [11] P.S. Dardas, T.G. Kelpis, V.N. Ninios, N.E. Mezilis, D.D. Tsikaderis, A.A. Pitsis, V.D. Thanopoulos, Successful transapical transcatheter prosthetic mitral paravalvular leak closure, Hell. J. Cardiol. 55 (6) (Nov–Dec 2014) 510–511 (No abstract available). [12] A. Iyisoy, C. Ozturk, T. Celik, S. Demirkol, F. Cingoz, M. Unlu, Z. Arslan, Percutaneous transapical closure of cardiac apex with an ADO-II device after successful transapical transcatheter prosthetic mitral paravalvular leak closure, Int. J. Cardiol. 189 (Jun 15 2015) 289–292, http://dx.doi.org/10.1016/j.ijcard.2015.04.076 (Epub 2015 Apr 15. No abstract available).
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
Computed tomography guided percutaneous transapical closure of cardiac apex after prosthetic mitral paravalvular leak closure Cengiz Ozturk a,⁎, Atila Iyisoy a, Turgay Celik a, Sevket Balta a, Ugur Bozlar b, Mustafa Demir a, Ali Osman Yildirim a, Adem Guler c a b c
Gulhane Military Medical Academy, School of Medicine, Department of Cardiology, Etlik, Ankara, Turkey Gulhane Military Medical Academy, School of Medicine, Department of Radiology, Etlik, Ankara, Turkey Gulhane Military Medical Academy, School of Medicine, Department of Cardiovascular Surgery, Etlik, Ankara, Turkey
a r t i c l e
i n f o
Article history: Received 11 June 2015 Accepted 26 June 2015 Available online 2 July 2015
Dear Editor, The transapical transcatheter approach for percutaneous interventions is performed in high-risk patients with peripheral vascular disease and when transseptal attempt failed. The apical access is traditionally performed through a left minithoracotomy at the fifth intercostal space under general anesthesia. But, there are some complications and risks like ventricular arrhythmias, ventricular tear and life-threatening surgical bleeding in the apical access even though it is a minimally invasive procedure [1]. Although new apical closure devices have been developed and tested in animals and humans, the apical closure remains a challenge in recent studies [2]. The cardiologists started to use the occluders to close the percutaneous apical accesses [3–11]. We report a case of a successful percutaneous closure of the apical access with a 4 mm ADO-II device after a standard transapical mitral paravalvular leak closure procedure without minithoracotomy with the computed tomography guidance. This case is the second from Turkey, so the first one was published recently in this journal [12]. In this second case, we used the CT guidance for optimal puncture of cardiac apex. A 44 year old female was admitted to our department with severe dyspnea (NHYA classes II–III). She had hemolytic anemia (hemoglobin level 8.0 g/dL, lactate dehydrogenase level was high). She had a history of mitral metallic prosthesis valve replacement in 1994. Transesophageal echocardiography (TEE) showed two severe mitral paravalvular leaks (6 and 9 mm) of the mitral valve prosthesis. Transesophageal echocardiography (TEE) showed two severe mitral paravalvular leaks (6 and
⁎ Corresponding author at: Department of Cardiology, Gulhane School of Medicine, Tevfik Saglam St., 06018, Etlik, Ankara, Turkey. E-mail address: [email protected] (C. Ozturk).
http://dx.doi.org/10.1016/j.ijcard.2015.06.121 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
Fig. 1. CT angiographic image of the patient marked with an arrow-1.
Fig. 2. CT angiographic image of the patient marked with an arrow-2.
38
Letter to the Editor
Fig. 3. Transapical approach with a needle externally.
Fig. 5. An AL-1 catheter is placed in the left atrium through the paravalvular mitral leak.
9 mm) of the mitral valve prosthesis. No active endocarditis was present. The patient was symptomatic because of two mitral paravalvular leaks and high risk for surgery. She had dyspnea during regular efforts. Firstly, we tried to close the leaks through the transseptal approach but we failed. We could not pass through the defects before. After that, we decided to try the transapical approach. Before the procedure, in order to obtain optimal puncture of the apical region of the left ventricle, a computed tomography was also performed. The radiologist marked the apex with an arrow at the sixth intercostal area and costochondral junction with left anterior 30° projection (Figs. 1, 2). Under general anesthesia, TEE, CT and fluoroscopic guidance, transapical cannulation of the left ventricle from the sixth intercostal area and midclavicular region with a needle was
performed and a 6 F sheath was inserted to the apical region. (Fig. 3). A Terumo hydrophilic wire was loaded on a right Judkins 6 F catheter and passed through the defects (Fig. 4). After the positioning of the catheter inside the left atrium (LA), the Terumo wire was replaced by an Amplatzer stiff wire. Then AL-1 guided the catheter to the LA (Figs. 5, 6). Through the guide catheter, a 10 mm × 5 mm Vascular Amplatzer plug was successfully deployed under 2D and 3D TEE and fluoroscopic imaging (Fig. 7). The two leaks were closured. TEE showed an appropriate position of the device and there was no residual mitral paravalvular leak after deployment. No complications were observed. After that, the placement of the myocardial occluder (4 mm ADO-II) (Figs. 8, 9) was performed through the delivery system, with a very small amount of blood
Fig. 4. A 0.38 inch guiding wire and a pigtail catheter are placed in the left atrium through the paravalvular mitral leak.
Fig. 6. A superstiff guiding wire is placed in the lower right pulmonary vein through the paravalvular mitral leak.
Letter to the Editor
Fig. 7. A delivery system and device are placed in the left atrium through the paravalvular mitral leak. Distal part of a vascular plug device is advanced through the delivery system.
loss and an acceptable sealing of the apical tear. There was also no scar on the chest wall. This approach with the computed tomography guidance can be done also easily and represents a further step to the routine percutaneous transapical heart valve procedures. The patient was discharged 6 days after the procedure in NYHA class I. The hemolytic indices also improved.
Conflict of interest There is no conflict of interest.
Fig. 8. Distal part of an ADO-II device is advanced through the delivery system to the apical region of the left ventricular apex.
39
Fig. 9. After leaving an ADO-II device in the apical region of the left ventricular apex.
References [1] L.K. von Segesser, G. Gerosa, M.A. Borger, E. Ferrari, Prevention and management of potential adverse events during transapical aortic valve replacement, J. Heart Valve Dis. 22 (2013) 276–286. [2] J. Blumenstein, J. Kempfert, A. Van Linden, et al., First-in-man evaluation of the transapical APICA ASCi access and closure device: the initial 10 patients, Eur. J. Cardiothorac. Surg. 44 (2013) 1057–1062. [3] H. Brinks, F. Nietlispach, V. Göber, et al., Transapical access closure: the TA PLUG device, Interact. Cardiovasc. Thorac. Surg. 17 (2013) 806–809. [4] Rajeev Fernando, David F. Briceno, Pranav Loyalka, Biswajit Kar, Transapical closure of mitral paravalvular leak over a surgically constructed mitral annulus, Int. J. Cardiol. 171 (2) (2014) 302–304, http://dx.doi.org/10.1016/j.ijcard.2013.11.072. [5] Saskia Pokorny, Katharina Huenges, Telse Bähr, Jan Hinnerk Hansen, Gunther Fischer, Justus Gross, Michael Morlock, Jochen Cremer, et al., Transapical mitral valved stent implantation: Enhanced survival and decreased paravalvular leakages, Int. J. Cardiol. 175 (3) (2014) 418–424, http://dx.doi.org/10.1016/j.ijcard.2014.11. 108. [6] Giuseppe Bruschi, Federico De Marco, Luca Botta, Alberto Barosi, Paola Colombo, Silvia Mauri, Aldo Cannata, Nuccia Morici, et al., Right anterior mini-thoracotomy direct aortic self-expanding trans-catheter aortic valve implantation: A single center experience, Int. J. Cardiol. 181 (2015) 437–442, http://dx.doi.org/10.1016/j.ijcard. 2014.11.108. [7] E. Ferrari, D. Locca, D. Berdajs, C. Marcucci, F. Gronchi, J. Lavanchy, R. Prêtre, P. Tozzi, Use of a ventricular septal defect occluder for apical closure in transapical aortic valve replacement, Innovations (Phila) 10 (1) (Jan–Feb 2015) 68–70, http://dx. doi.org/10.1097/IMI.0000000000000118. [8] J. Blumenstein, J. Kempfert, W. Kim, C. Liebetrau, H. Möllmann, T. Walther, Transapical access and closure devices: rationale and current status, Expert. Rev. Cardiovasc. Ther. 11 (12) (Dec 2013) 1613–1617, http://dx.doi.org/10.1586/ 14779072.2013.847788. [9] H. Brinks, F. Nietlispach, V. Göber, L. Englberger, P. Wenaweser, B. Meier, T. Carrel, C. Huber, Transapical access closure: the TA PLUG device, Interact. Cardiovasc. Thorac. Surg. 17 (5) (Nov 2013) 806–809, http://dx.doi.org/10.1093/icvts/ivt309 (discussion 809–10. Epub 2013 Jul 9). [10] L. Tang, Z. Fang, X. Hu, J. Tang, X. Shen, X. Lu, Y. Zhao, J. Li, S. Zhou, Non-surgical repair of ventricular septal rupture after acute myocardial infarction, Int. J. Cardiol. 185 (Mar 17 2015) 328–332, http://dx.doi.org/10.1016/j.ijcard.2015.03.144 (Epub ahead of print). [11] P.S. Dardas, T.G. Kelpis, V.N. Ninios, N.E. Mezilis, D.D. Tsikaderis, A.A. Pitsis, V.D. Thanopoulos, Successful transapical transcatheter prosthetic mitral paravalvular leak closure, Hell. J. Cardiol. 55 (6) (Nov–Dec 2014) 510–511 (No abstract available). [12] A. Iyisoy, C. Ozturk, T. Celik, S. Demirkol, F. Cingoz, M. Unlu, Z. Arslan, Percutaneous transapical closure of cardiac apex with an ADO-II device after successful transapical transcatheter prosthetic mitral paravalvular leak closure, Int. J. Cardiol. 189 (Jun 15 2015) 289–292, http://dx.doi.org/10.1016/j.ijcard.2015.04.076 (Epub 2015 Apr 15. No abstract available).
