All you want know about Percutaneous PVL closure ; Why, When, and How

1. Percutaneous PVL closure
An Overview
Ahmed ElBorae, MSc

2. • Why
• When
• How
Agenda

3. Size of the problem
Ruizet al. PVL-ARC Endpoint Definitions. JAC C VOL. 69, NO. 1 6, 2 017
210.000 prosthetic valve surgery / Year

4. LAA
IAS
AO
Extensive MV annular calcification and resorption

5. Calvert et al. Circ, 2016
Translated into mortality

6. Percutaneous or Surgical ?
Surgical
• Redo surgery mortality 13%
(1st), 15 % (2nd),37% (3rd)*
• Repeat PVL after redo
surgery ≈ 30%
Percutaneous
• Less invasive
• Procedural success rate 86%
• Less complications
* Echevarria JR, et al. Eur J Cardiothorac surg.1991;5:523-6

7. • Why
• When
• How
Agenda

8. Indications
• Symptomatic congestive heart
failure
• Clinically significant hemolysis
• Rocking prosthesis
• Large leaks >30% of sewing ring
• Infective endocarditis (within 6
months)
Contraindications

9. Agenda
• Why
• When
• How

10. • Echocardiography (3D TEE,TTE)
• Cardiac CT (Trans-apical)
• Laboratory (Haptoglobin↓, Bilirubin, LDH, Retics,
Schistocytes↑), Check Iron and Folic level
PVL assessment

11. 12
6
3 9
115 Size, number, and location
Speaking the same language

12. 5 11
Mahmoud H. Added value of 3D TEE in management of mitral pvl Echocardiography.2020;00:1–11

13. MPR 3D-Color TEE
ERO
Area 0.13 cm, Length 0.65 cm, and width 0.28 cm for 3D-ERO area, length, and width > grade III or more PVL
Mahmoud H. Added value of 3D TEE in management of mitral pvl Echocardiography.2020;00:1–11

14. Fluoroscopic correlation
LAO Caudal

16. Eleid et al. Techniques and Outcomes for the Treatment of PVLCirc Cardiovasc Interv. 2015;8:e001945
LCCNCC/RCC

17. Approaches
Retrograde

19. Approaches
Stephan noble. Cardiovascular Medicine 2012;15(9):245–252
Steerable sheath (Agilis SJM)
Percutaneous or surgical

20. Sorajja et al. PVL 30 days outcome. Circ Cardiovasc Interv. 2011;4:314-321
Rail support
1
2
3

21. Percutaneous: Apical (femoro-apical rail)

24. Toolkit

25. Closure devices
Calvert et al. Circ, 2016
Occlutech (CE)
AVP

27. Technical tips
• Team approach
• Large defects > ( 2 small AVP II is better than single larger one)
• ACT monitoring is crucial
• Prosthesis occluders movement
• Hemodynamic monitoring especially when using rail

28. Mitral PVL

29. 12
6
3
9

30. 6
9

34. Plug.1,2 cables Guide wire
Delivery sheath Delivery sheath
Guide wire
Plug .1,2 cables
Plug.3 cable
Sequential deployment technique (Anchor wire)

37. Aortic PVL

38. *
*

42. Thank You