Catheterization and Cardiovascular Interventions 85:1104–1105 (2015)
VALVULAR AND STRUCTURAL HEART DISEASES Letter to the Editor Percutaneous Paravalvular Leak Closure After TAVI: A Demanding Approach TO THE EDITOR
In a recent issue of Catheterization & Cardiovascular Interventions Gafoor et al. [1] described their experience regarding percutaneous paravalvular leak (PVL) closure after transcatheter aortic valve implantation (TAVI) with a CoreValve (Medtronic, Minneapolis, MN) device. This is a technically demanding procedure with unpredictable results but in expert hands — as demonstrated — can be safely conducted. However, several considerations should be taken into account. First, as wisely underlined by the authors [1], such a procedure should be performed on an elective basis, in stable patients and after comprehensive evaluation of the PVL. Still, if under an emergency, a range of bailout techniques in an attempt to ameliorate PVL has previously been described in detail (namely TAVI-inTAVI, Snare, Remove-and-Reposition, Balloon Repositioning techniques) [2–5]. Second, it should be addressed that it may not always be feasible to cross the bioprosthesis’ nitinol frame struts in the “correct” direction regarding the PVL. This is due the fact that the nitinol frame of the CoreValve prosthesis is covered by a pericardial skirt the height of which (toward the prosthesis outflow tract) varies from 12 to 32 mm (starting from the prosthesis’ inflow tract; Fig. 1). However, this is a question that cannot be answered preprocedurally but should be kept in mind to avoid unnecessary (or potentially harmful) manipulations in case of initial failure to cross the struts. Third, Gafoor et al. [1] emphasize the issue of “high access” through the frame struts as a means of easier deliverability of the PVL closure device. Additionally, it should be considered as a tactic to secure that the proximal lobe of the Amplatzer vascular plug (St. Jude C 2014 Wiley Periodicals, Inc. V
Fig. 1. CoreValve sketch in which varying pericardial skirt height is illustrated. Numbers in polygons indicate strut nodes; distance from node to node is 4 mm. Horizontal and diagonal lines depict pericardial skirt in different planes.
Medical, Minneapolis, MN) will not protrude in the bioprosthesis’ outflow tract. Of note, valve leaflets — when open — reach a height 16 mm (from the inflow level; Fig. 1). Therefore, in the scenario of a “low access” of the guidewire through the frame struts (i.e., just above the lowest end of the pericardial skirt; 12 mm from the inflow level) the aforementioned complication could be a risk. Finally, operators should also be prepared for the theoretical risk of unintentional bioprosthesis’ repositioning (valve “pop-up”) during catheter manipulations, especially in a relatively highly implanted prosthesis. Manolis Vavuranakis, MD, PhD, FESC, FACC, FSCAI Dimitrios A. Vrachatis, MD, MSc, PhD Dimitrios Tousoulis, MD, PhD, FESC, FACC 1st Department of Cardiology, Hippokration Hospital National and Kapodistrian University of Athens Athens, Greece
Conflict of interest: Vavuranakis Manolis is a proctor for CoreValve (Medtronic Inc.) Received 4 August 2014; Revision accepted 18 September 2014 DOI: 10.1002/ccd.25669 Published online 30 September 2014 in Wiley Online Library (wileyonlinelibrary.com)
Percutaneous Paravalvular Leak Closure After TAVI
REFERENCES 1. Gafoor S, Franke J, Piayda K, Lam S, Bertog S, Vaskelyte L, Hofmann I, Sievert H. Paravalvular leak closure after transcatheter aortic valve replacement with a self-expanding prosthesis. Catheter Cardiovasc Interv 2014;84:147–154. 2. Vavouranakis M, Vrachatis DA, Toutouzas KP, Chrysohoou C, Stefanadis C. “Bail out” procedures for malpositioning of aortic valve prosthesis (CoreValve). Int J Cardiol 2010;145:154–155. 3. Vavuranakis M, Vrachatis D, Stefanadis C. Corevalve aortic bioprosthesis: Repositioning techniques. JACC Cardiovasc Interv 2010;3:565; author reply 565–566.
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4. Vavuranakis M, Kariori M, Vrachatis D, Aznaouridis C, Kalogeras K, Moldovan C, Stefanadis C. “Balloon withdrawal technique” to correct prosthesis malposition and treat paravalvular aortic regurgitation during TAVI. J Invasive Cardiol 2013;25: 196–197. 5. Ussia GP, Barbanti M, Ramondo A, Petronio AS, Ettori F, et al. The valve-in-valve technique for treatment of aortic bioprosthesis malposition an analysis of incidence and 1-year clinical outcomes from the italian CoreValve registry. J Am Coll Cardiol 2011;57: 1062–1068.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
VALVULAR AND STRUCTURAL HEART DISEASES Letter to the Editor Percutaneous Paravalvular Leak Closure After TAVI: A Demanding Approach TO THE EDITOR
In a recent issue of Catheterization & Cardiovascular Interventions Gafoor et al. [1] described their experience regarding percutaneous paravalvular leak (PVL) closure after transcatheter aortic valve implantation (TAVI) with a CoreValve (Medtronic, Minneapolis, MN) device. This is a technically demanding procedure with unpredictable results but in expert hands — as demonstrated — can be safely conducted. However, several considerations should be taken into account. First, as wisely underlined by the authors [1], such a procedure should be performed on an elective basis, in stable patients and after comprehensive evaluation of the PVL. Still, if under an emergency, a range of bailout techniques in an attempt to ameliorate PVL has previously been described in detail (namely TAVI-inTAVI, Snare, Remove-and-Reposition, Balloon Repositioning techniques) [2–5]. Second, it should be addressed that it may not always be feasible to cross the bioprosthesis’ nitinol frame struts in the “correct” direction regarding the PVL. This is due the fact that the nitinol frame of the CoreValve prosthesis is covered by a pericardial skirt the height of which (toward the prosthesis outflow tract) varies from 12 to 32 mm (starting from the prosthesis’ inflow tract; Fig. 1). However, this is a question that cannot be answered preprocedurally but should be kept in mind to avoid unnecessary (or potentially harmful) manipulations in case of initial failure to cross the struts. Third, Gafoor et al. [1] emphasize the issue of “high access” through the frame struts as a means of easier deliverability of the PVL closure device. Additionally, it should be considered as a tactic to secure that the proximal lobe of the Amplatzer vascular plug (St. Jude C 2014 Wiley Periodicals, Inc. V
Fig. 1. CoreValve sketch in which varying pericardial skirt height is illustrated. Numbers in polygons indicate strut nodes; distance from node to node is 4 mm. Horizontal and diagonal lines depict pericardial skirt in different planes.
Medical, Minneapolis, MN) will not protrude in the bioprosthesis’ outflow tract. Of note, valve leaflets — when open — reach a height 16 mm (from the inflow level; Fig. 1). Therefore, in the scenario of a “low access” of the guidewire through the frame struts (i.e., just above the lowest end of the pericardial skirt; 12 mm from the inflow level) the aforementioned complication could be a risk. Finally, operators should also be prepared for the theoretical risk of unintentional bioprosthesis’ repositioning (valve “pop-up”) during catheter manipulations, especially in a relatively highly implanted prosthesis. Manolis Vavuranakis, MD, PhD, FESC, FACC, FSCAI Dimitrios A. Vrachatis, MD, MSc, PhD Dimitrios Tousoulis, MD, PhD, FESC, FACC 1st Department of Cardiology, Hippokration Hospital National and Kapodistrian University of Athens Athens, Greece
Conflict of interest: Vavuranakis Manolis is a proctor for CoreValve (Medtronic Inc.) Received 4 August 2014; Revision accepted 18 September 2014 DOI: 10.1002/ccd.25669 Published online 30 September 2014 in Wiley Online Library (wileyonlinelibrary.com)
Percutaneous Paravalvular Leak Closure After TAVI
REFERENCES 1. Gafoor S, Franke J, Piayda K, Lam S, Bertog S, Vaskelyte L, Hofmann I, Sievert H. Paravalvular leak closure after transcatheter aortic valve replacement with a self-expanding prosthesis. Catheter Cardiovasc Interv 2014;84:147–154. 2. Vavouranakis M, Vrachatis DA, Toutouzas KP, Chrysohoou C, Stefanadis C. “Bail out” procedures for malpositioning of aortic valve prosthesis (CoreValve). Int J Cardiol 2010;145:154–155. 3. Vavuranakis M, Vrachatis D, Stefanadis C. Corevalve aortic bioprosthesis: Repositioning techniques. JACC Cardiovasc Interv 2010;3:565; author reply 565–566.
1105
4. Vavuranakis M, Kariori M, Vrachatis D, Aznaouridis C, Kalogeras K, Moldovan C, Stefanadis C. “Balloon withdrawal technique” to correct prosthesis malposition and treat paravalvular aortic regurgitation during TAVI. J Invasive Cardiol 2013;25: 196–197. 5. Ussia GP, Barbanti M, Ramondo A, Petronio AS, Ettori F, et al. The valve-in-valve technique for treatment of aortic bioprosthesis malposition an analysis of incidence and 1-year clinical outcomes from the italian CoreValve registry. J Am Coll Cardiol 2011;57: 1062–1068.
Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).
