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The Anchor Wire Technique for Aortic Paravalvular Leak Closure
The Anchor Wire Technique for Aortic Paravalvular Leak Closure Paul Sorajja, MD
A 55-year-old man was referred for percutaneous closure of aortic paravalvular regurgitation. The patient previously underwent cardiac surgery with placement of bi-leaflet mechanical prostheses (St. Jude Medical, St. Paul, MN) in both the aortic and mitral positions. A and B, At baseline, transthoracic echocardiography shows severe paravalvular regurgitation in multiple apical long-axis views (arrowheads). C, The paravalvular defect was crossed using a 6-Fr multipurpose catheter and a 260-cm, angle-tipped, extra-stiff Glidewire (arrow) (Terumo, Ann Arbor, MI). Care was taken to ensure the wire passed through the paravalvular defect external to the mechanical aortic valve prosthesis (arrowheads, C and D). E, The glidewire was passed antegrade through the mechanical aortic valve safely (arrow) to provide adequate support for passage of a 6-Fr Flexor Shuttle sheath into the left ventricle (arrowhead) (Cook Medical, Bloomington, IN). F, A 0.032″ extra-stiff Amplatz wire is inserted (arrowhead). G, A 12-mm Type II Amplatzer vascular plug (arrowhead) is positioned across the paravalvular defect with the Amplatz wire (arrow) remaining in the left ventricle, followed by ascending aortography. H, Final image after decoupling of the plug (arrow) from the delivery cable. Repeat fluoroscopy to document normal leaflet motion is performed. Ao, Ascending aorta; LA, left atrium; LV, left ventricle.
164 PROSTHETIC VALVE
KEY POINTS • For patients undergoing percutaneous closure of aortic paravalvular regurgitation, the use of an anchor wire saves procedure time by reducing the need to re-cross the defect in the event additional or different occluders are required. A 6-Fr Flexor sheath will accommodate both a 12-mm AVP-2 plug and 0.032″ extra-stiff Amplatz wire. • Prior to release of the device occluder, aortography is performed to confirm relief of regurgitation and demonstrate patency of the coronary arteries, which may arise near the treated paravalvular defects. • Recording of normal leaflet motion is important to demonstrate no leaflet impingement with occluder placement.
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PROSTHETIC VALVE 165
A 55-year-old man was referred for percutaneous closure of aortic paravalvular regurgitation. The patient previously underwent cardiac surgery with placement of bi-leaflet mechanical prostheses (St. Jude Medical, St. Paul, MN) in both the aortic and mitral positions. A and B, At baseline, transthoracic echocardiography shows severe paravalvular regurgitation in multiple apical long-axis views (arrowheads). C, The paravalvular defect was crossed using a 6-Fr multipurpose catheter and a 260-cm, angle-tipped, extra-stiff Glidewire (arrow) (Terumo, Ann Arbor, MI). Care was taken to ensure the wire passed through the paravalvular defect external to the mechanical aortic valve prosthesis (arrowheads, C and D). E, The glidewire was passed antegrade through the mechanical aortic valve safely (arrow) to provide adequate support for passage of a 6-Fr Flexor Shuttle sheath into the left ventricle (arrowhead) (Cook Medical, Bloomington, IN). F, A 0.032″ extra-stiff Amplatz wire is inserted (arrowhead). G, A 12-mm Type II Amplatzer vascular plug (arrowhead) is positioned across the paravalvular defect with the Amplatz wire (arrow) remaining in the left ventricle, followed by ascending aortography. H, Final image after decoupling of the plug (arrow) from the delivery cable. Repeat fluoroscopy to document normal leaflet motion is performed. Ao, Ascending aorta; LA, left atrium; LV, left ventricle.
164 PROSTHETIC VALVE
KEY POINTS • For patients undergoing percutaneous closure of aortic paravalvular regurgitation, the use of an anchor wire saves procedure time by reducing the need to re-cross the defect in the event additional or different occluders are required. A 6-Fr Flexor sheath will accommodate both a 12-mm AVP-2 plug and 0.032″ extra-stiff Amplatz wire. • Prior to release of the device occluder, aortography is performed to confirm relief of regurgitation and demonstrate patency of the coronary arteries, which may arise near the treated paravalvular defects. • Recording of normal leaflet motion is important to demonstrate no leaflet impingement with occluder placement.
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H
PROSTHETIC VALVE 165