CASE REPORT

IVUS guidance in percutaneous closure of aortic paraprostheticleak

P. Avila • F. Sarnago Cebada • J. Elızaga •

F. Fernandez-Aviles

Received: 11 August 2011 / Accepted: 11 January 2012 / Published online: 25 February 2012

� Japanese Association of Cardiovascular Intervention and Therapeutics 2012

Abstract Severe aortic regurgitation due to paraprosthetic

leak appears in 1–5% of patients with previous aortic valve

replacement. Surgical management is the treatment of choice

but has high morbidity and mortality and leak recurrence is

not uncommon. Different approaches to percutaneous closure

have been tried. Transesophageal echocardiography (TEE) is

a key factor to measure and localize leakages. Performing

TEE during the procedure implies general anesthesia and

prolongs procedure and fluoroscopy times. We report the

case of an aortic paraprosthetic leak percutaneous closure

using intravascular ultrasound to guide the procedure.

Keywords Intravascular ultrasound � Aortic

regurgitation � Paraprosthetic leak � Percutaneous closure

Introduction

Severe paravalvular leak is a possible complication after

valve replacement surgery and can cause heart failure and

hemolytic anemia. Although surgical management is the

treatment of choice, it involves high morbidity and mor-

tality so percutaneous closure has been described, using

TEE as a guide during the procedure but usually involving

general anesthesia. We present a case of a percutaneous

aortic paraprosthetic leak closure guided by IVUS.

Case report

We report the case of a 44-year-old woman with aortic

and mitral bileaflet mechanical valves, sizes 21 and 29

respectively (CarboMedics Inc, Austin, TX, USA) after an

episode of acute endocarditis seven months ago, and a

torpid post-operative phase with multiple complications

(renal failure, cardiac tamponade, mechanical ventilation

associated pneumonia and gastrointestinal bleeding). Six

months after surgery she complained of shortness of breath

on mild to moderate exertion and the follow-up transtho-

racic echocardiogram (TTE) showed moderate to severe

aortic eccentric regurgitation due to a posterior aortic para-

prosthetic leak. TEE showed a periaortic leak in the valve

ring adjacent to the non-coronary sinus (approximately 45�of the circumference) that caused severe aortic regurgita-

tion (Fig. 1a, b, Video 1). Due to high risk of severe

complications, reoperation was not allowed and she was

referred to our catheterization laboratory for percutaneous

closure.

The procedure was performed without general anesthe-

sia. Baseline angiography (Videos 2A and B) confirmed the

severity of the aortic regurgitation and a minimal diameter

of 4 mm was measured (Fig. 2). The leak was crossed with

a 0.01400 straight tip hydrophilic coated guidewire (Terumo

Medical Corp., Somerset, NJ, USA), using retrograde

access and a multipurpose 6 F guide catheter. IVUS was

performed (intracoronary echocardiogram device, Boston

Scientific, Natick, MA, USA) through the defect, finding an

anfractuous pathway, superficial calcification and measur-

ing minimal diameter of 4.9 mm (Fig. 3). A 5 9 10 mm

Amplatzer Vascular Plug III (AGA Medical, Golden Val-

ley, MN, USA) device was deployed with a JR 7.5 F

SheathLess Eucath catheter (Asahi Intecc., Pathumthani,

Thailand) without interfering with the prosthesis discs

Electronic supplementary material The online version of thisarticle (doi:10.1007/s12928-012-0099-y) contains supplementarymaterial, which is available to authorized users.

P. Avila (&) � F. Sarnago Cebada � J. Elızaga �F. Fernandez-Aviles

Cardiology Department, Hospital General Universitario

Gregorio Maranon, c/Dr. Esquerdo 46, 28007 Madrid, Spain

e-mail: pabloavilaalonso@gmail.com

123

Cardiovasc Interv and Ther (2012) 27:137–139

DOI 10.1007/s12928-012-0099-y

(Fig. 4, Video 3) and with minimal residual aortic regur-

gitation in the final angiography (Video 4). Procedure total

time was 72 min. The patient was discharged 24 h after the

intervention without complications. Three months later,

she was in NYHA functional class I/IV and a control TTE

showed mild paraprosthetic aortic regurgitation (Video 5).

Discussion

Severe aortic regurgitation due to paraprosthetic leak

appears in 1–5% [1] of patients. Clinical manifestations

include congestive cardiac failure or hemolytic anemia.

Surgical management is the treatment of choice but con-

veys a high morbidity and mortality and leak recurrence is

not uncommon [2]. Recently, some series and case reports

of percutaneous closure, with different kinds of devices and

approaches, have been published [3, 4]. TEE is essential to

quantify and locate the leak, in order to choose properly the

device size [5]. During the procedure it is particularly

useful in closing mitral leaks but general anesthesia and

intubation are required, increasing procedure times and the

risk of complications especially in some patients (pul-

monary diseases). In aortic leaks it is not always used and

the device size is chosen based on the previous TTE study

and the angiographic findings. If TTE guidance is not

available during the procedure, isolated quantitative anal-

ysis of the aortic regurgitation in the aortography may not

be accurate enough.

Fig. 1 Short axis (45�) and long axis (135�) transesophageal echocardiogram still images of the aortic paraprosthetic leak adjacent to the non-

coronary sinus (arrows)

Fig. 2 RAO aortography still picture showing the posterior para-

prosthetic aortic leak with an anfractuous pathway. 4 mm of minimal

diameter was measured (arrow). RAO right anterior oblique

Fig. 3 IVUS image showing minimal leak diameter between the

aortic wall (asterisk) and the mechanical valve ring (arrows). IVUSintravascular ultrasound

138 P. Avila et al.

123

A sheathless catheter was chosen to minimize the

puncture site and bleeding complications, on the basis that

a 7.5 F possesses about the same outer diameter as a 5 F

sheath introducer. It also enhances catheter trackability

even in tortuous pathways.

Our case shows how using intravascular ultrasound

(IVUS) can measure leak diameters. Additionally, general

anesthesia is avoided and can be performed by the inter-

ventional cardiologist without the need of an echocardi-

ographist and anesthestist. To our knowledge, it is the first

case reported using this image technique.

An IVUS transducer has emission frequencies of

20–40 MHz which confer it high spatial resolution but low

depth (less than 10 mm) [6] so it can make it difficult to

apply in daily practice. Taking into account that prostheses

are easily visualized and most leaks referred to percuta-

neous closure are usually small, we believe IVUS can be

helpful during the procedure. Nonetheless, a good previous

TEE is still crucial to evaluate the leak, planify the pro-

cedure and predict its success. It also has other limitations.

First, it is a catheter designed for coronary study needing

angioplasty guidewire (0,01400) that gives low support to go

through very small or anfractuous leaks. Furthermore, it

does not have color Doppler so the evaluation of the final

result relies on angiography. Finally, the axis of the IVUS

may not be parallel to the aortic valve ring so the diameter

could be overestimated.

Conclusion

This case illustrates that IVUS use is safe, feasible and can

be useful to guide percutaneous closure of paravalvular

leaks, especially aortic. More cases and studies are required

to evaluate its real value in this and other similar

procedures.

Conflict of interest The authors report no financial relationships or

conflicts of interest regarding the content herein.

References

1. Rallidis LS, Moyssakis IE, Ikonomidis I, Nihoyannopoulos P.

Natural history of early aortic paraprosthetic regurgitation: a five-

year follow-up. Am Heart J. 1999;138:351–7.

2. Akins CW, Bitondo JM, Hilgenberg AD, Vlahakes GJ, Madsen JC,

MacGillivray TE. Early and late results of the surgical correction

of cardiac prosthetic paravalvular leaks. J Heart Valve Dis. 2005;

14:792–9 (discussion 799–800).

3. Pate GE, Al Zubaidi A, Chandavimol M, Thompson CR, Munt BI,

Webb JG. Percutaneous closure of prosthetic paravalvular leaks:

case series and review. Catheter Cardiovasc Interv. 2006;68:

528–33.

4. Sivakumar K, Shahani J. Transcatheter closure of paravalvular

mitral prosthetic leak with resultant hemolysis. Int J Cardiol.

2007;115:E39–40.

5. Cortes M, Garcıa E, Garcıa-Fernandez MA, Gomez JJ, Perez-

David E, Fernandez-Aviles F. Usefulness of transesophageal

echocardiography in percutaneous transcatheter repairs of para-

valvular mitral regurgitation. Am J Cardiol. 2008;101:382–6.

6. Nissen SE. Application of intravascular ultrasound to characterize

coronary artery disease and assess the progression or regression of

atherosclerosis. Am J Cardiol. 2002;89:24–31.

Fig. 4 RAO still picture showing the Amplatzer Vascular Plug III

(5 9 10 mm) device through the aortic paraprosthetic leak just before

deployment. RAO right anterior oblique

IVUS guidance in percutaneous closure 139

123