Clarke, Andrew

Lamana, Arvin

Raffel, Owen Christopher

Saireddy, Ramakrishna

Scalia, Gregory M.

Subban, Vijayakumar

Walters, Darren L.

University of Queensland eSpace

Accepted Manuscript
Title: Immediate Closure of ParavalvularLeak after
TranscatheterAortic Valve Implantation
Author: Ramakrishna Saireddy VijayakumarSubban DrArvin
Lamana Andrew Clarke Gregory M Scalia Owen Christopher
Raffel Darren L Walters
PII: S1443-9506(14)00507-1
DOI: http://dx.doi.org/doi:10.1016/j.hlc.2014.05.011
Reference: HLC 1611
To appear in:
Received date: 31-12-2013
Revised date: 10-5-2014
Accepted date: 25-5-2014
Please cite this article as: Saireddy R, Lamana DA, Clarke A, Scalia
GM, Raffel OC, Walters DL, Immediate Closure of ParavalvularLeak after
TranscatheterAortic Valve Implantation, Heart, Lung and Circulation (2014),
http://dx.doi.org/10.1016/j.hlc.2014.05.011
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Title page 
 
Title 
Immediate Closure of ParavalvularLeak after TranscatheterAortic Valve Implantation 
 
Running head 
Closure of Paravalvular Regurgitation 
 
Authors and Affiliations: 
Dr Ramakrishna Saireddy FRACP#1 
DrVijayakumarSubban DM1 
DrArvinLamana FRACP1 
Dr Andrew Clarke FRACS1 
Dr Gregory M Scalia FRACP* 
Dr Owen Christopher Raffel, FRACP1 
Prof Darren L Walters FRACP* 
#First author 
1Heart Lung Institute, 
The Prince Charles Hospital, 
Rode Road ,ChermsideBrisbane.QLD. 
*University of Queensland 
St Lucia. Brisbane. QLD 
 
Corresponding Author and Address for correspondence: 
Dr. Ramakrishna Saireddy 
Fellow in Interventional Cardiology 
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Cardiology Program 
The Prince Charles Hospital 
Rode Road, Chermside 
Brisbane, Qld, Australia 4032 
Email: kittsreddy@yahoo.com 
Tel.: +61 7 3139 4000 
Fax: +61 7 3139 4819 
 
Key words 
Paravalvular, Amplatzer, TAVR 
 
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Manuscript 
Authors and Affiliations: 
Dr Ramakrishna Saireddy FRACP#1 
Dr VijayakumarSubban DM1 
Dr Arvin Lamana FRACP1 
Dr Andrew Clarke FRACS1 
Dr Gregory M Scalia FRACP* 
Dr Owen Christopher Raffel, FRACP1 
Prof Darren L Walters FRACP* 
#First author 
1Heart Lung Institute, 
The Prince Charles Hospital, 
Rode Road ,ChermsideBrisbane.QLD. 
*University of Queensland 
St Lucia. Brisbane. QLD 
 
Corresponding Author and Address for correspondence: 
Dr. Ramakrishna Saireddy 
Fellow in Interventional Cardiology 
Cardiology Program 
The Prince Charles Hospital 
Rode Road, Chermside 
Brisbane, Qld, Australia 4032 
Email: kittsreddy@yahoo.com 
Tel.: +61 7 3139 4000 
Fax: +61 7 3139 4819 
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Trans catheter aortic valve implantation (TAVI) is increasingly used to treat severe aorticstenosis 
(AS) in surgical high-risk groups. Mortality and reduction in symptoms weresimilar in the two 
groups[1]. Para valvular leak (PVL) was more common in the TAVIgroup[1] and is an 
independent predictor of mortality[1]. We report a case of successfulimmediate closure of 
moderate to severe PVL with an Amplatzer Vascular Plug III (AVPIII). 
 
A 75 year-old female presented with severe symptomatic AS. Logistic Euroscore was 35%and 
STS mortality score was 15%. The aortic annulus diameter by transthoracicechocardiogram was 
22mm. CT reconstruction (3Mensio Medical Imaging BV,Netherlands) showed annulus 
perimeter of76mm and area 438mm2. There was significantcalcium deposition at the annulus 
(Figure 1e). A 23mm Edwards Sapien XT valve (Edwards Lifesciences, Irvine, California) was 
chosen for TAVI. Due to tortuous andcalcific illio-femoral arteries, trans-aortic access was used 
for TAVI.Following valve implantation trans-oesophageal echocardiography (TEE) 
showedmoderate to severe PVL (Figure 1a & 1c). Dilatation of the valve with a 45 x 25 
mmCristal balloon (BALT, France) failed to reduce PVL. Due to concern that the first valvewas 
deployed too high another Sapien XT 23 mm valve was deployed more distallywithout any 
change to the PVL (Figure 2b). It was then decided to seal the PVL with AVP III. A JL4 catheter 
with a glidewire was used to cross the PVL after which a 6 FrCook sheath was used to deliver a 
10mm x 5mm AVP III (St. Jude, St. Paul, Minnesota)to seal the PVL (Figures 2c & 2d). PVL was 
reduced to grade 0-1(Figures 1c & 1d). Arepeat TOE confirmed stable aortic valve prosthesis 
with mild PVL and preserved LVsystolic function. Unfortunately, the patient died 14 days later 
after developingpneumonia and subsequent multi-organ failure. 
 
Given the annular dimensions, ideally a 26mm valve is recommended. We used a 23mm valve 
due tosignificant focal calcification extending from annulus into LVOT. This meant high risk of 
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aortic root rupture with a 26mm valve[3]. Alternatively an underfilled 26mm valve could have 
been considered. 
 
High or low implantation of the valve and inadequate apposition of the valve to theannulus either 
due to device annulus size mismatch, suboptimal balloon expansion(Edwards-Sapien) or 
significant localised calcium deposits are the predominant causes ofPVL[2]. In the case 
described above, we took a stepwise approach to resolve PVL. As PVL is an independent 
marker of mortality in these patients, immediate PVL closure post TAVI should theoretically 
improve overall outcome in this group of patients. Long term follow up of a large cohort of 
patients with significant PVL undergoing PVL closurein the same setting will ultimately guide us 
in the right direction. 
 
References 
1. Susheel K. Kodali, Mathew R. Williams, Craig R. Smith, Lars G. Svensson, Ph.D., 
John G. Webb, Raj R. Makkar, et al.Two-Year Outcomes after Transcatheter or Surgical Aortic 
ValveReplacement. N Engl J Med 2012; 366:1686-95. 
2.Ganesh Athappan, EshanPatvardhan, E. Murat Tuzcu, Lars Georg Svensson, Pedro A.Lemos, 
Chiara Fraccaro, et al.Incidence, Predictors, and Outcomes of Aortic Regurgitation After 
Transcatheter AorticValve Replacement. J Am CollCardiol. April 2013; Vol 61 (15):1585-1595. 
3.Barbanti M, Yang TH, RodèsCabau J, Tamburino C, Wood DA, Jilaihawi H, et al. Anatomical 
and Procedural Features Associated with Aortic Root Rupture During Balloon-Expandable 
Transcatheter Aortic Valve Replacement. Circulation. 2013 Jul 16;128(3):244-53. 
 
 
 
 
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Figure legends 
 
Figure 1: TEE Long axis and short axis views of PVL after TAVI (a & c respectively). 
Long and short axis views of PVL after AVP III implantation (b & d). 3D reconstruction 
(3 Mensio) showing a chunk of calcium (arrow) at the aortic annulus extending into LV 
(e). 3D TEE image showing relationship of the device to Mitral and Aortic valves (f). 
 
Figure 2: Aortogram after first Edwards valve implantation (a). Second Edwards valve 
deployed (b). AVP III implantation (c & d). 
 
Figure 3: Post mortem images showing relationship of the valves and AVP III to native 
structures. Aortic valve cusp (A), first Edwards valve (B), second Edwards valve (C) and 
AVP III device (D). 
 
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*Figure


Immediate Closure of Paravalvular Leak After Transcatheter Aortic Valve Implantation

https://espace.library.uq.edu.au/view/UQ:348812/UQ348812_OA.pdf

Immediate Closure of Paravalvular Leak After Transcatheter Aortic Valve Implantation

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