- Email: [email protected]
Amplatzer Devices Are Not Geometrically Adapted to Close Paravalvular Leaks
774
CORRESPONDENCE
Amplatzer Devices Are Not Geometrically Adapted to Close Paravalvular Leaks To the Editor: I read with great interest the article by Kennedy and colleagues [1]. Their finding strengthens the initial “word of caution” emphasized by several authors regarding the usefulness of the Amplatzer device for percutaneous closure of periprosthetic mitral leaks [2, 3]. Because mortality increases with the number of previous open surgeries, percutaneous techniques are increasingly used to treat prosthetic paravalvular leaks (PVLs). The closure of paravalvular mitral leak with an Amplatzer device was first reported by Boudjemline and colleagues in 2002 [4]. Although the PVL closure with a percutaneous device is a minimally invasive therapeutic alternative, the current literature documents ambiguous results. The Amplatzer device rarely closes the defect entirely, probably because of its circular shape that is not designed for PVL closure, which commonly exhibits a crescent shape. Larger occluding devices are used frequently in an attempt to close the defect. The larger the device, the higher the probability of interference with the prosthesis. Merin and colleagues [5] reported a case of impingement on valve leaflet motion. In our case, the device caused both a recurrent leak and interference with the mechanical mitral prosthesis [3]. This example shows that the currently used devices for transcatheter percutaneous closure of PVL are not geometrically adapted to the anatomy of these defects. Therefore, further effort in developing defect-specific devices is needed to improve outcomes. Ovidio A. Garcia-Villarreal, MD Department of Cardiac Surgery Hospital of Cardiovascular Diseases and the Chest No. 34, IMSS Sierra Nayarita 143 Col. Virginia Tafich Santa Catarina, Nuevo Leon 66374 Mexico e-mail: [email protected]
References
MISCELLANEOUS
1. Kennedy JLW, Mery CM, Kern JA, Bergin JD. Mitral stenosis caused by an Amplatzer occluder device used to treat a paravalular leak. Ann Thorac Surg 2012;93:2058 – 60. 2. Smith CR, Stamou SC, Merhi WM, Hooker RI. Repair of paravalvular prosthetic mitral valve leaks with septal occluder devices in severely high-risk patients: a word of caution. Interact Cardiovasc Thorac Surg 2012;15:544 – 6. 3. Garcia-Villarreal OA, Alonso-Rodriguez O. Percutaneous closure of prosthetic mitral paravalvular leak with Amplatzer device: a word of caution. Rev Mex Cardiol 2011;22:182– 4. [Spanish] 4. Boudjemline Y, Abdel-Massih T, Bonhoeffer P, et al. Percutaneous closure of a paravalvularmitral regurgitation with an Amplatzer and coil prostheses. Arch Mal Coeur Vaiss 2002; 95:483– 6. 5. Merin O, Bitran D, Fink D, Asher E, Silberman S. Mechanical valve obstruction caused by an occlusion device. J Thorac Cardiovasc Surg 2007;133:806 –7.
Ann Thorac Surg 2013;95:770 –5
the STS database on the effects of Fontan techniques on early outcomes. They demonstrated that patients undergoing an extracardiac conduit were more likely to require a Fontan takedown or revision and had longer hospital stays. Importantly, adjusted mortality was similar for both techniques. Similarly, we have found rates of mortality and significant reoperation to be equivalent in our experience of 73 lateral tunnel and 192 extracardiac conduit Fontan procedures (0 vs. 1% and 4 vs. 3%, respectively). Ultimately, the choice of one technique of Fontan would depend not only on differences in short-term, but also long-term outcomes. In our team, we are convinced that the extracardiac conduit leads to optimal flows in the venous pathways and fewer atrial arrhythmias [2]; however, as Stewart and colleagues demonstrated [1], this topic remains extremely controversial. Our current policy is to exclusively perform the fenestrated extracardiac conduit at 4 to 6 years of age, later than in the North American experience, and we suspect that the effects of using an adult-sized conduit would be decreased in older patients. We also suspect that technical mistakes might result in a higher incidence of Fontan takedown and revision. Because of the conceptual simplicity of the extracardiac conduit, the technical difficulties related to this procedure seem unrecognized. A slight rotation of the conduit at the level of the superior anastomosis may lead to a partial obstruction of the right pulmonary artery. Performing the lower anastomosis without cardioplegic arrest requires clamping of the right atrium, a practice shown to occasionally result in obstruction of the inferior vena cava by obstructing eustachian valve tissue and closure of the coronary sinus [3]. Finally, the differences in the length of stay observed might be related more to the patency of a fenestration than the actual technique. The authors state that only intention to fenestrate was recorded, but it is known that fenestrations in lateral tunnel baffles have far greater patency rates than in extracardiac conduits. We have thus developed a peculiar technique for maintaining long-term fenestration patency [4]. Fenestration clearly has an effect on the amount of chest drainage after Fontan surgery [5], and we believe that this might explain the differences observed in the hospital length of stay seen in extracardiac conduits in this series. The study by Stewart and colleagues has raised some thoughtprovoking questions and will certainly be an impetus for further research. Ajay J. Iyengar, MBBS (Hons), BMedSci Igor E. Konstantinov, MD, PhD Christian P. Brizard, MD Yves d’Udekem, MD, PhD Department of Cardiac Surgery Royal Children’s Hospital Flemington Rd Melbourne, VIC 3052 Australia e-mail: [email protected]
Dr d’Udekem is a Career Development Fellow of the National Heart Foundation of Australia (CR 10M 5339).
Unreliable Associations Between Type of Fontan and Early Outcome? To the Editor: We read with interest and surprise the article by Stewart and colleagues [1] demonstrating a detailed analysis of the data from © 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Iyengar is a co-funded Postgraduate Scholar of the National Health and Medical Research Council/National Heart Foundation of Australia (APP1038802) and holds a Royal Australasian College of Surgeons Catherine Marie Enright Kelly Postgraduate Scholarship.
0003-4975/$36.00
CORRESPONDENCE
Amplatzer Devices Are Not Geometrically Adapted to Close Paravalvular Leaks To the Editor: I read with great interest the article by Kennedy and colleagues [1]. Their finding strengthens the initial “word of caution” emphasized by several authors regarding the usefulness of the Amplatzer device for percutaneous closure of periprosthetic mitral leaks [2, 3]. Because mortality increases with the number of previous open surgeries, percutaneous techniques are increasingly used to treat prosthetic paravalvular leaks (PVLs). The closure of paravalvular mitral leak with an Amplatzer device was first reported by Boudjemline and colleagues in 2002 [4]. Although the PVL closure with a percutaneous device is a minimally invasive therapeutic alternative, the current literature documents ambiguous results. The Amplatzer device rarely closes the defect entirely, probably because of its circular shape that is not designed for PVL closure, which commonly exhibits a crescent shape. Larger occluding devices are used frequently in an attempt to close the defect. The larger the device, the higher the probability of interference with the prosthesis. Merin and colleagues [5] reported a case of impingement on valve leaflet motion. In our case, the device caused both a recurrent leak and interference with the mechanical mitral prosthesis [3]. This example shows that the currently used devices for transcatheter percutaneous closure of PVL are not geometrically adapted to the anatomy of these defects. Therefore, further effort in developing defect-specific devices is needed to improve outcomes. Ovidio A. Garcia-Villarreal, MD Department of Cardiac Surgery Hospital of Cardiovascular Diseases and the Chest No. 34, IMSS Sierra Nayarita 143 Col. Virginia Tafich Santa Catarina, Nuevo Leon 66374 Mexico e-mail: [email protected]
References
MISCELLANEOUS
1. Kennedy JLW, Mery CM, Kern JA, Bergin JD. Mitral stenosis caused by an Amplatzer occluder device used to treat a paravalular leak. Ann Thorac Surg 2012;93:2058 – 60. 2. Smith CR, Stamou SC, Merhi WM, Hooker RI. Repair of paravalvular prosthetic mitral valve leaks with septal occluder devices in severely high-risk patients: a word of caution. Interact Cardiovasc Thorac Surg 2012;15:544 – 6. 3. Garcia-Villarreal OA, Alonso-Rodriguez O. Percutaneous closure of prosthetic mitral paravalvular leak with Amplatzer device: a word of caution. Rev Mex Cardiol 2011;22:182– 4. [Spanish] 4. Boudjemline Y, Abdel-Massih T, Bonhoeffer P, et al. Percutaneous closure of a paravalvularmitral regurgitation with an Amplatzer and coil prostheses. Arch Mal Coeur Vaiss 2002; 95:483– 6. 5. Merin O, Bitran D, Fink D, Asher E, Silberman S. Mechanical valve obstruction caused by an occlusion device. J Thorac Cardiovasc Surg 2007;133:806 –7.
Ann Thorac Surg 2013;95:770 –5
the STS database on the effects of Fontan techniques on early outcomes. They demonstrated that patients undergoing an extracardiac conduit were more likely to require a Fontan takedown or revision and had longer hospital stays. Importantly, adjusted mortality was similar for both techniques. Similarly, we have found rates of mortality and significant reoperation to be equivalent in our experience of 73 lateral tunnel and 192 extracardiac conduit Fontan procedures (0 vs. 1% and 4 vs. 3%, respectively). Ultimately, the choice of one technique of Fontan would depend not only on differences in short-term, but also long-term outcomes. In our team, we are convinced that the extracardiac conduit leads to optimal flows in the venous pathways and fewer atrial arrhythmias [2]; however, as Stewart and colleagues demonstrated [1], this topic remains extremely controversial. Our current policy is to exclusively perform the fenestrated extracardiac conduit at 4 to 6 years of age, later than in the North American experience, and we suspect that the effects of using an adult-sized conduit would be decreased in older patients. We also suspect that technical mistakes might result in a higher incidence of Fontan takedown and revision. Because of the conceptual simplicity of the extracardiac conduit, the technical difficulties related to this procedure seem unrecognized. A slight rotation of the conduit at the level of the superior anastomosis may lead to a partial obstruction of the right pulmonary artery. Performing the lower anastomosis without cardioplegic arrest requires clamping of the right atrium, a practice shown to occasionally result in obstruction of the inferior vena cava by obstructing eustachian valve tissue and closure of the coronary sinus [3]. Finally, the differences in the length of stay observed might be related more to the patency of a fenestration than the actual technique. The authors state that only intention to fenestrate was recorded, but it is known that fenestrations in lateral tunnel baffles have far greater patency rates than in extracardiac conduits. We have thus developed a peculiar technique for maintaining long-term fenestration patency [4]. Fenestration clearly has an effect on the amount of chest drainage after Fontan surgery [5], and we believe that this might explain the differences observed in the hospital length of stay seen in extracardiac conduits in this series. The study by Stewart and colleagues has raised some thoughtprovoking questions and will certainly be an impetus for further research. Ajay J. Iyengar, MBBS (Hons), BMedSci Igor E. Konstantinov, MD, PhD Christian P. Brizard, MD Yves d’Udekem, MD, PhD Department of Cardiac Surgery Royal Children’s Hospital Flemington Rd Melbourne, VIC 3052 Australia e-mail: [email protected]
Dr d’Udekem is a Career Development Fellow of the National Heart Foundation of Australia (CR 10M 5339).
Unreliable Associations Between Type of Fontan and Early Outcome? To the Editor: We read with interest and surprise the article by Stewart and colleagues [1] demonstrating a detailed analysis of the data from © 2013 by The Society of Thoracic Surgeons Published by Elsevier Inc
Dr Iyengar is a co-funded Postgraduate Scholar of the National Health and Medical Research Council/National Heart Foundation of Australia (APP1038802) and holds a Royal Australasian College of Surgeons Catherine Marie Enright Kelly Postgraduate Scholarship.
0003-4975/$36.00