Anastasius M.

Ilardi F.

Lerakis S.

English

Archivio della ricerca - Università degli studi di Napoli Federico II

J A C C : C A S E R E P O R T S V O L . 4 , N O . 1 , 2 0 2 2ª 2 0 2 2 T H E A U T HO R S . P U B L I S H E D B Y E L S E V I E R O N B E H A L F O F T H E A M E R I C A NC O L L E G E O F C A R D I O L O G Y F O U N DA T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E RT H E C C B Y - N C - N D L I C E N S E ( h t t p : / / c r e a t i v e c o mm o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 / ) .EDITORIAL COMMENTMultimodality Imaging Is Key for aSuccessful Paravalvular Leak Repair*Federica Ilardi, MD, PHD,a,b Malcolm Anastasius, MBBS, MM, PHD,c Stamatios Lerakis, MD, PHDcP aravalvular leak (PVL) is a complicationfollowing surgical or percutaneous valvereplacement, more frequently seen in themitral than aortic position.Presenting symptoms are usually related to devel-opment of heart failure or hemolytic anemia.Although in symptomatic patients PVL interventionhas been associated with improved event-free sur-vival compared to conservative management, surgicalintervention (PVL repair or valve replacement) hasbeen associated with a high rate of morbidity, mor-tality and suboptimal results, especially in those whohave undergone multiple prior cardiac operations andhave significant comorbidities (1). In recent years,percutaneous PVL closure has emerged as a viable,less invasive alternative to surgical treatment, beingparticularly attractive for high-risk patients withmultiple comorbidities. When performed in experi-enced centers, the rate of procedural success ap-proaches 90% (2). In practice, however, there is asignificant learning curve to perform successfulpercutaneous PVL repair due to the complex nature ofthe procedure. The procedure also requires closecollaboration between imaging specialists, surgeons,and interventionalists (3). Advanced cardiac imagingis an integral part of the evaluation and guidance ofpercutaneous PVL repair.ISSN 2666-0849*Editorials published in JACC: Case Reports reflect the views of theauthors and do not necessarily represent the views of JACC: Case Reportsor the American College of Cardiology.From the aDepartment of Advanced Biomedical Sciences, Federico IIUniversity of Naples, Naples, Italy; bMediterranea Cardiocentro, Naples,Italy; and the cDepartment of Cardiology, Mount Sinai Heart, New York,New York, USA.The authors attest they are in compliance with human studies commit-tees and animal welfare regulations of the authors’ institutions and Foodand Drug Administration guidelines, including patient consent whereappropriate. For more information, visit the Author Center.In this issue of JACC: Case Reports, Espinoza Ruedaet al (4) describes the clinical case of a 72-year-oldman who was hospitalized with congestive heartfailure and a new grade III holosystolic murmur at theapex 4 years following coronary artery bypass graft-ing with concomitant aortic and mitral valvereplacement due to severe stenosis of both valves andtricuspid valve annuloplasty. Transesophageal echo-cardiography (TEE) revealed severe mitral PVL.Cardiac computed tomography (CT) confirmed thePVL defect location and size, and was used to obtain a3-dimensional (3D) printed model to simulate PVLclosure. The percutaneous PVL repair was performedsuccessfully, with implantation of an Occlutech par-avalvular leak device. The procedure was guided bythe EchoNavigator system comprising of real-timefusion of echocardiography and fluoroscopic imag-ing. At the end of the procedure, there was minimalresidual PVL and the patient experienced nocomplications.This case shows the role of multimodality imagingto firstly define the location, shape and extent of thePVL; and secondly, to plan and guide the percuta-neous PVL repair procedure.A multimodality imaging approach is pivotal in thepreprocedural planning of PVL closure to overcomethe limitations of different imaging techniques, toproperly identify prosthetic valvular dysfunctionmechanism, to quantify the severity of the prostheticvalvular defect, and to anatomically define the PVL toappropriately plan the therapeutic intervention.Echocardiography is the first-line imaging tool forevaluation of PVL. Although 2D echocardiography canprovide approximation of the position, severity, andpath of paravalvular regurgitation, 3D imaging en-ables a comprehensive assessment of the anatomicallocation, shape, and circumferential extent of thePVL, which provides important detail in planningand guiding the percutaneous repair (5,6). Thehttps://doi.org/10.1016/j.jaccas.2021.11.003J A C C : C A S E R E P O R T S , V O L . 4 , N O . 1 , 2 0 2 2 Ilardi et alJ A N U A R Y 5 , 2 0 2 2 : 4 2 – 4 3 Cardiac Imaging for PVL Repair43echocardiographic grading of PVL severity has yet tobe well standardized and remains a limitation (7).In the present case, PVL severity estimation withtransthoracic echocardiography was mainly basedupon qualitative parameters. Cardiac CT providesimportant complementary detail in PVL evaluation. Itprovides high accuracy for determining the presence,size, and shape of the PVL, and identifies surroundingcalcifications (8,9). Although its usefulness inassessing PVL anatomical features is key, cardiac CTis less sensitive for the assessment of regurgitationseverity. Conversely, cardiac magnetic resonanceimaging has been shown to have incremental utilityover echocardiography by providing both anatomicalfeatures and quantification of the severity of the PVL.Cardiac magnetic resonance imaging quantification ofparavalvular regurgitation can be performed byplanimetry of the anatomic regurgitant orifice area,and also through phase-contrast velocity mappinganalysis (7,10).One of the challenges of percutaneous PVL closureis understanding the complex PVL shape in order tochoose the appropriate device and the size of thedevice. In the case presented, the utility of an ex vivo3D-printed model to simulate the PVL closure hasbeen shown; this modeling step was useful inensuring minimal interference of the device withprosthetic valve leaflet function. Although growingevidence supports the use of cardiac 3D-printedmodels in several clinical applications (preoperativeplanning, intervention simulation, intraoperativesimulation, etc), the main limitation of this technol-ogy is the high cost inherent to the equipment andsoftware needed to start a 3D-printing facility (11).However, cost-effective analysis has shown thefeasibility of manufacturing low-cost 3D-printed car-diac models fulfilling the highest clinical and tech-nical requirements (12). Ongoing efforts to developnew affordable materials and 3D printing technolo-gies could increase accessibility of this tool acrossinstitutions and improve patients’ quality of care.Finally, the use of echocardiographic-fluoroscopyfusion imaging, through the real-time overlay of 2D,3D, or color Doppler images onto the fluoroscopicimage enhances procedural guidance by localizationof the PVL defect allowing more efficient PVL deviceclosure (12,13).This case shows the utility of multimodality im-aging in supporting successful percutaneous repair ofmitral bioprosthetic PVL. The integration of advancedcardiac imaging modalities including 3D printing canovercome limitations of individual techniques andguide complex and challenging procedures.FUNDING SUPPORT AND AUTHOR DISCLOSURESThe authors have reported that they have no relationships relevant tothe contents of this paper to disclose.ADDRESS FOR CORRESPONDENCE: Dr StamatiosLerakis, Mount Sinai Heart, 1 Gustave L. Levy Place,Box 1030, New York, New York 10029-6574, USA.E-mail: stamatios.lerakis@mountsinai.org.RE F E RENCE S1. Taramasso M, Maisano F, Denti P, et al. Sur-gical treatment of paravalvular leak: long-termresults in a single-center experience (up to 14years). J Thorac Cardiovasc Surg. 2015;149:1270–1275.2. Millan X, Skaf S, Joseph L, et al. Transcatheterreduction of paravalvular leaks: a systematic re-view and meta-analysis. Can J Cardiol. 2015;31:260–269.3. Sorajja P, Bae R, Lesser JA, Pedersen WA.Percutaneous repair of paravalvular prostheticregurgitation: patient selection, techniques andoutcomes. Heart. 2015;101:665–673.4. Espinoza Rueda MA, Alcántara Meléndez MA,González RM, et al. Successful closure of para-valvular leak using computed tomography imagefusion and planning with 3-dimensional printing.J Am Coll Cardiol Case Rep. 2022;4:36–41.5. Johri AM, Yared K, Durst R, et al. Three-dimensional echocardiography-guided repair ofsevere paravalvular regurgitation in a bio-prosthetic and mechanical mitral valve. Eur JEchocardiogr. 2009;10:572–575.6. Hamilton-Craig C, Boga T, Platts D, et al. Therole of 3D transesophageal echocardiographyduring percutaneous closure of paravalvular mitralregurgitation. J Am Coll Cardiol Img. 2009;2:771–773.7. Ruiz CE, Hahn RT, Berrebi A, et al. ParavalvularLeak Academic Research Consortium. Clinical trialprinciples and endpoint definitions for para-valvular leaks in surgical prosthesis. Eur Heart J.2018;39:1224–1245.8. Lesser JR, Han BK, Newell M, Schwartz RS,PedersenW,Sorajja P.Useof cardiacCTangiographyto assist in the diagnosis and treatment of aorticprosthetic paravalvular leak: a practical guide.J Cardiovasc Comput Tomogr. 2015;9:159–164.9. O’Neill AC, Martos R, Murtagh G, et al. Practicaltips and tricks for assessing prosthetic valves anddetecting paravalvular regurgitation using cardiacCT. J Cardiovasc Comput Tomogr. 2014;8:323–327.10. Altiok E, Frick M, Meyer CG, et al. Comparisonof two- and three-dimensional transthoracicechocardiography to cardiac magnetic resonanceimaging for assessment of paravalvular regurgi-tation after transcatheter aortic valve implanta-tion. Am J Cardiol. 2014;113:1859–1866.11. Vukicevic M, Mosadegh B, Min JK, Little SH.Cardiac 3D printing and its future directions. J AmColl Cardiol Img. 2017;10:171–184.12. Gómez-Ciriza G, Gómez-Cía T, Rivas-González JA, Velasco Forte MN, Valverde I.Affordable three-dimensional printed heartmodels. Front Cardiovasc Med. 2021;8:642011.13. Thaden JJ, Sanon S, Geske JB, et al. Echocar-diographic and fluoroscopic fusion imaging forprocedural guidance: an overview and early clin-ical experience. J Am Soc Echocardiogr. 2016;29:503–512.KEY WORDS 3-dimensional imaging,3-dimensional printing, computed tomography,mitral valve, valve repair

Multimodality Imaging Is Key for a Successful Paravalvular Leak Repair

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Multimodality Imaging Is Key for a Successful Paravalvular Leak Repair

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