Mitral Valve Leaks Research Articles

Transcatheter mitral valve leak closure with left atrial appendage closure device: kill two birds with one stone.

Transcatheter mitral valve leak closure with left atrial appendage closure device: kill two birds with one stone.

How and where the mitral valve leaks in functional mitral regurgitation

Background and AimIt remains unknown how and where the mitral valve leaks in functional mitral regurgitation. The objective of the current study was to quantify the geometry and position of the leaflet free edges in order to reveal gapping mechanism of the mitral valve, and develop a plug technique to prevent mitral regurgitation. MethodsEight porcine mitral valves were sutured onto a dilated annulus in an in-vitro experiment to simulate valve closure at hydrostatic transmitral pressure. Eight sonocrystals were attached to the mitral valve leaflet free edges. Papillary muscles (PM) were adjusted to the normal position, and subsequently to positions of asymmetric and symmetric papillary muscle displacement. Sonocrystal positions were measured and analyzed. ResultsThe leaflet free edges in the central and medial regions moved medially, apically, and posteriorly from normal to asymmetric PM position. Gapping potential in the posteromedial region increased. Medial displacement of the free edges sometimes generated a gap in the anterolateral region in the asymmetric PM position. The leaflet free edges moved posteriorly and apically from the normal to symmetric PM position, and generated a dumb-bell shaped gap. ConclusionsAsymmetric PM position impairs the posteromedial coaptation region due to leaflet tenting, and compromises the anterolateral coaptation region due to medial leaflet displacement. The gaps include multiple sites along the coaptation line. Symmetric PM position impairs valve coaptation due to valve tenting only. The gap is a symmetrical dumb-bell shape. The findings are crucial for development of the plug technique to prevent mitral regurgitation.

Progressive breathlessness post mitral valve replacement

Abstract Paravalvular leak occurs in 1–5% patients following surgical valve replacement and is associated with complications including haemolysis, heart failure and endocarditis. Re-do surgery is difficult with mortality rates approaching 16%. Percutaneous closure of mitral valve leaks with occluder devices is a viable alternative to repeat sternotomy; however, clinicians should be aware of contra-indications which include active endocarditis. Management of paravalvular leak is complex and success requires multi-disciplinary approach with cardiothoracic surgeons, clinical, imaging and interventional cardiologists.

Surgical vs. catheter-based paravalvular mitral valve leak closure (trans apical approach). Early results. Single center experience.

Following surgical mitral valve replacement paravalvular leaks may occur in up to 17% of patients. A significant fraction of these patients present with a symptoms of heart failure and/or anaemia. Conventional surgical closure is associated with increased morbidity and mortality. Alternative transcatheter closure has been developed and being introduced into the clinical practice with a reasonable success. More evidence is needed to compare the efficacy and safety between surgical and catheter-based paravalvular mitral valve leak closure.

Sutureless 3f Enable valve implantation concomitant with mitral valve surgery.

Interest in aortic sutureless bioprostheses is growing. Here, we evaluate the feasibility of performing aortic sutureless valve replacement concomitant with mitral valve surgery using the 3f Enable prosthesis. Of the 198 3f Enable® valve implantation procedures carried out in our unit between March 2011 and October 2014, 15 were performed concomitant with mitral valve surgery (8 bioprosthetic replacements and 7 annuloplasties). The mean age and logistic EuroSCORE were 76 ± 6 years and 10.2 ± 4.8, respectively. The procedural success rate of aortic sutureless valve implantation was 100%. Mean cross-clamping and cardiopulmonary bypass times were 113.9 ± 35 and 150- ± 43 min, respectively. No reclamping in response to a sutureless paravalvular leakage (PVL) was needed. One grade 1 leak was observed at the time of discharge. There was no perioperative mortality. Pacemaker implantation was required in 1 case (6.6%). Initial follow-up (median = 8 months, range 1-6) showed no new aortic PVL; mean and peak transprosthetic gradients and the orifice area were 11.1 ± 2.5 and 18.4 ± 4.9 mmHg and 1.7 ± 0.4 cm(2), respectively. One grade 2 and two grade 1 mitral valve leaks were detected following annuloplasty. 3f Enable® sutureless valve implantation combined with mitral valve surgery appears feasible and the results presented here are encouraging. This procedure has the potential to simplify surgery in a cohort of high-risk patients for whom transcatheter aortic valve replacement is not an effective option. Larger studies should be conducted to confirm these observations.

REAL-WORLD COST-EFFECTIVENESS OF THE MITRACLIP FOR THE TREATMENT OF HIGH RISK MITRAL REGURGITATION

Mitral regurgitation (MR), a disorder of the heart in which the mitral valve leaks resulting in volume overload for the heart, is associated with increased risk of heart failure and mortality. Standard care for MR is surgical repair or replacement of the mitral valve. Patients at high risk for surgical intervention, such as those with functional MR, are often relegated to symptomatic management with medical therapy which is associated with poor outcomes. The MitraClip is a transcatheter device which performs percutaneous edge-to-edge repair to treat MR. We evaluated the real-world clinical and cost effectiveness of MitraClip in high-risk MR patients. Data for patients receiving MitraClip was obtained from a prospective registry of high-risk MR patients treated at the Montréal Heart Institute (MHI) in Québec from December 2010 to May 2013. These patients were propensity matched on baseline characteristics and medical therapy to medically treated MR patients followed at the MHI Heart Failure Clinic from 2008 to 2011. Cohorts were compared on clinical and economic outcomes, including overall survival (OS), quality of life (QoL), complications/adverse events, emergency room (ER) visits, hospitalizations, surgical intervention, and clinic visits. A decision analytic model was developed to assess the 10-year cost-effectiveness of MitraClip vs. medical therapy in patients with high-risk MR. Clinical effectiveness, QoL, and resource utilization were obtained from the matched cohort analysis. Survival for each group was extrapolated beyond follow-up to 10 years using Weibull regression analysis. Unit costs were obtained from the MHI. Costs and benefits were discounted at 5% per annum. Treatment with MitraClip was associated with an incremental gain of 1.34 quality-adjusted life years (QALYs) compared to medical therapy. The incremental cost-effectiveness ratio (ICER) was $36,543 per QALY gained. Therapy with the MitraClip is a cost-effective alternative to medical therapy for high-risk patients with MR.

Repair of paravalvular prosthetic mitral valve leaks with septal occluder devices in severely high-risk patients: a word of caution

Paravalvular leak following a mitral valve replacement is a complication seen in approximately 1 of 10 replacements. The corrective method has traditionally been reoperation. Septal occluder devices are more commonly being utilized as an alternative percutaneous correction method. We report the use of septal occluder devices in the repair of mitral paravalvular leak in two patients at severely high EuroSCORE II mortality risk. In both patients, the occluder devices became unstable, leading to a recurrence of severe paravalvular leak.

Two‐stage percutaneous closure of mitral periprosthetic valvular leak

Periprosthetic valve leak can develop as a complication of valve replacement surgery and may manifest as symptomatic valvular regurgitation, heart failure, or haemolysis. We report a case of severe mitral periprosthetic valve leak requiring a two-stage percutaneous closure technique with multiple Amplatzer® III vascular plugs.

Acquired Von Willebrand Syndrome In Mitral Valve Leak

AbstractAbstract 4657 BackgroundSeveral studies have shown that between 15% to 25% of patients with severe aortic stenosis present bleeding episodes that may be attributed to an acquired von Willebrand syndrome (AVWS). Until now, to our knowledge, no association of AVWS with mitral valve disfunction has been reported. Design and MethodsFour patients with mitral valve leak presented acquired abnormalities of von Willebrand factor (VWF) and a bleeding history. Two of them presented severe bleedings requiring blood transfusions. All of them were within an adequate range of oral anticoagulation. ResultsPrior to surgery, these patients presented an APTT prolonged and in two of them the closure time determined by the platelet function analyzer (PFA-100®) (with COL/ADP and COL/Epi) was prolonged also. Factor VIII procoagulant activity (FVIII:C), VWF antigen (VWF:Ag), VWF ristocetin cofactor activity (VWF:RCo) and VWF collagen binding (VWF:CB) were considerably elevated and the VWF multimers in plasma, showed a lower relative proportion of the high molecular weight VWF multimers (HMWM), to some extent similar to type 2A congenital von Willebrand disease (VWD). In two of them, the VWF:RCo/VWF:Ag or VWF: CB/VWF:Ag ratios were less than normal range (>0.7) while in the other two were normal. After surgery, FVIII:C, and VWF properties were extremely increased and the ratios VWF:RCo/VWF:Ag and VWF: CB/VWF:Ag > 0.7. After surgery, FVIII:C, VWF:Ag, VWF:RCo and VWF:CB increased considerably. The ratios were > 0.7. The PFA-100® (COL/ADP and COL/Epi) was corrected in the two patients who had it prolonged. The multimeric VWF profile were also corrected in all of them. ConclusionsThe present study describes acquired VWF qualitative alterations for the first time in mitral valve leak. When such alterations are important they may be associated or to contribute to a bleeding diathesis. This problem was reported previously in aortic valve stenosis in relationship with a suspected very high shear stress. This situation may be not usually present in mitral valve stenosis, but it seems that it must occur in the presence of mitral valve leak. Consequently, the AVWS should be taken into account in patients with mitral valve leak that present a bleeding diathesis, not explained by an excess of oral anticoagulation. ACKNOWLEDGEMENTSThis work was supported by the Fondo de Investigación Sanitaria, F.I.S. Carlos III, Ministerio de Sanidad, Spain (FIS PI# 07/0229), and Consellería de Innovación e Industria, Xunta de Galicia (INCITE08ENA916109ES). Disclosures:No relevant conflicts of interest to declare.

Real-time three-dimensional TEE guidance of a paravalvular mitral valve leak closure procedure

Real-time three-dimensional TEE guidance of a paravalvular mitral valve leak closure procedure

Transapical left ventricular access for difficult to reach interventional targets in the left heart

Interventional targets may be virtually "excluded" due to vascular access problems or complex previous surgical procedures. This study reviews our experience using transapical ventricular puncture to gain direct access to the systemic ventricle. Patient 1 (74 years, 2 previous sternotomies), patient 2 (66 years, 5 previous sternotomies), and patient 5 (69 years, 3 previous sternotomies) with prosthetic valves had paravalvular mitral valve leaks. Patient 3 (6.3 years, 2 previous sternotomies) with an extracardiac Fontan conduit, had a significant residual leak after two previous surgical attempts of patch closure of a severely regurgitant right atrioventricular valve. Patient 4 (10 months) had failure of standard ablation of the posteroseptal region of the mitral valve with persistent life-threatening episodes of ventricular tachycardia. Procedures were performed under general anesthesia. Entry site was percutaneous in three patients and in two (and one conversion) a mini-thoracotomy was used. Sheaths were placed (6 F) using standard Seldinger technique, followed by the procedure as required. Direct surgical closure of the puncture site was done in 4 patients and in patient 3, a percutaneous vascular occlusion device was used. Easy and immediate access was obtained in all patients. The paravalvular leaks were crossed within seconds and completely closed with Amplatzer occluders. In patient 3 the valve was crossed using a Brokenbrough needle and a 12-mm Amplatzer device was placed in the patch leak. Patient 4 was successfully ablated using a 7-F irrigated catheter endo- and epicardially. Complications were in the percutaneous puncture group: in one patient a coronary artery was punctured and in one a hemothorax developed. Direct left ventricular puncture offers a very useful alternative access site in selected patients to reach "inaccessible" targets for certain percutaneous interventions in patients where standard approaches may be impossible or difficult.

Percutaneous Treatment of Mitral Valve Periprosthetic Leakage. An Alternative to High-Risk Surgery?

Periprosthetic mitral valve regurgitation due to paravalvular leakage is one of the complications of valve replacement surgery. We report a series of eight patients with severe symptomatic periprosthetic mitral regurgitation in whom surgery could not be performed because of the high risk. All patients were assigned to percutaneous closure of periprosthetic mitral valve leaks using an Amplatzer duct occluder. The procedure was successful in five patients. A significant reduction in periprosthetic regurgitation and a clinical improvement were observed in four of the patients. The procedure was unsuccessful in three patients: in two due to interference with the prosthesis discs; in the other, because it was not possible to pass through the leak. One of these three patients died a few hours after the procedure due to severe stroke. Percutaneous closure of paravalvular leakage in patients at a high surgical risk is technically feasible and has an acceptable clinical success rate.

Percutaneous Treatment of Periprosthetic Mitral Valve Leaks: Is it Just a Futile Exercise?

We report the percutaneous exclusion of a mitral peri-prosthetic valvular leak performed with the Amplatzer vascular plug. Device dislodgement occurred a few days later and surgical repair was ultimately required.

Detection of prosthetic mitral valve leak: A comparative study using transesophageal echocardiography, transthoracic echocardiography, and auscultation

Paravalvular leakage is a major complication of prosthetic valve dysfunction. Sixty-one subjects with valvular heart disease who had received prosthetic mitral valve replacement 5 months to 5 years before (43 received a porcine prosthesis and 18 received Bjork-Shiley valve prostheses) were evaluated for this complication. Careful auscultation was performed by two experienced cardiologists followed by transthoracic and transesophageal echocardiography. Physiologic leaks were detected in all Bjork-Shiley valves, but in only 30% of porcine valves using transesophageal echocardiography. These regurgitant jets were flame-like, with mean low velocities of 50 +/- 12.3 cm/sec and 48 +/- 18.2 cm/sec in the two types of valves. Neither transthoracic echocardiography nor auscultation could detect physiological regurgitant jets. Ten cases with paravalvular leak were detected by transesophageal echocardiography and subsequently demonstrated by left ventriculography (7 porcine, 3 Bjork-Shiley valves). Pathologic regurgitant jets were seen as high-velocity, systolic-retrograde turbulent flow across the prosthesis. However, only 6 cases of prosthetic valve dysfunction were detected by transthoracic echocardiography, 4 cases of mild paravalvular leakage went undetected. Thirteen of the 61 subjects had an apical systolic murmur and suspected prosthetic valve leakage; in 10 of the 13 cases the findings corresponded to those obtained by transesophageal echocardiography. In 3 cases of double valve replacement with Bjork-Shiley valves the magnitude of the leakage was overestimated by auscultation.