Paravalvular Leak Closure Case Presentation Samir Kapadia, MD Professor of Medicine Director, Cardiac Catheterization Laboratories Cleveland Clinic DISCLOSURE : NONE

Samir Kapadia, MD I have no real or apparent conflicts of interest to report. My presentation will include off label discussions: Valves

Clinical Presentation 79 year old lady s/p St. Jude #19 AV in 1990 s/p St. Jude # 23 MV in 2004 with CABG (L-AD and SVG to OM) AF, DDD pacemaker Severe hemolytic anemia worsening over last 1 year. 30 blood transfusions last year. 8 in last 2 months. Class III CHF (gets SOB moving from chair to chair) Question of aortic valve leaflet dysfunction

Echocardiogram TTE EF – normal (55%) AV – gradient p/m = 9/5 mm Hg MV – gradient p/m = 20/8 mm Hg RVSP = 62 mm Hg TEE (difficult to pass a probe, esophageal stricture, needed direct visualization with scope to pass the probe) 3+ MR paravalvular

TEE

Labs Blood cultures (-) LDH = 3618 U/L AST = 166 U/L T Bili 1.9 mg/dL Haptoglobin <20 mg/dL BNP = 443 pg/mL

Procedure Conscious sedation Image fusion and planning of the procedure stiff wire in LV will not exteriorize if needed TA puncture

Approaches to PVL Closure Kapadia and Tuzcu, Circ Cardiovasc Interv 2011;4;308-310

Procedure Conscious sedation Image fusion and planning of the procedure stiff wire in LV will not exteriorize if needed TA puncture Assessment of valves and coronaries Initial procedure with fluoro and ICE Pediatric probe

Where is the Leak? Foster GP et al, Ann Thorac Surg 1998; 65:1025–1031

Biplane TEE

CTA

Marking of Area of Interest: Aortic Root

Marking of Area of Interest: Leak

Marking of Area of Interest: TS Puncture

Rotational CT in Cath Lab

Fusion

Markings on the Fluoro

Checking Valve Motion

Transseptal Puncture

Hemodynamics Mean LA = 24 mm Hg, V wave = 44 mm Hg

Crossing the Defect

No Gradient Across AS

Advancing the Delivery Sheath

Attempt at Deploying Muscular VSD Device

TEE with Deployment

Interference with Disc

Doppler Gradients Before Deployment With Deployment

Deployment of PDA Device

PDA Device

Gradients Unchanged Before After

Functioning Valve After Release

LA pressure Before Deployment With Deployment Mean LA = 24 mm Hg, V wave = 44 mm Hg Mean LA = 18 mm Hg, V wave = 30 mm Hg

F/u Labs Day Prior Post Day 1 LDH = 3618 U/L AST = 166 U/L T Bili 1.9 mg/dL Haptoglobin <20 mg/dL BNP = 443 pg/mL LDH = 2303 U/L AST = 80 U/L T Bili 1.3 mg/dL Haptoglobin <20 mg/dL one month Hg = 10.4

Thank YOU For ATTENTION