Crushing The Pringle: Worsening Paravalvular Leak Following Mitral Valve-in-Ring

Crushing the Pringle: Worsening Paravalvular Leak Following Mitral Valve-in-Ring
Yuanting Zha, MD, MPH; David M. Buric, MD; Adam S. Weinstein, MD

Brigham and Women’s Hospital, Boston, MA, USA
Introduction
Paravalvular leak (PVL) is a well-known complication after mitral valvular prosthesis placement, and rare
after mitral valve repair. With the emergence of catheter-based mitral interventions, patients are
presenting for valve-in-ring (ViR) or valve-in-valve (ViV) procedures, adding a second prosthesis where
PVL can occur. We present a case of worsening PVL following a ViR procedure, treated with a vascular
plug.
Case
A 64 year-old male with history of tricuspid and mitral valve (MV) annuloplasties presented with
increasing fatigue and dyspnea. He was diagnosed with significant mitral stenosis and regurgitation. As a
high-risk surgical candidate, he was scheduled for ViR transcatheter mitral valve replacement.
Pre-deployment transesophageal echo (TEE) revealed trace mitral PVL on the posterior aspect of the
valve. A 23 mm Edwards Sapien 3 transcatheter heart valve was deployed into the patient’s 26 mm
Edwards Physio complete annuloplasty ring. Post-deployment TEE revealed severe PVL at the previously
noted location, outside the MV ring. A 10 mm Amplatzer Vascular Plug II was placed, which reduced the
leak from severe to mild.
Discussion
PVL can affect up to 20% of surgical mitral replacements; however, only 1-5% warrant intervention. The
incidence of PVL due to annuloplasty ring dehiscence following MV repair ranges from 1-2.3%, and
occurs most commonly at the posterior annulus due to its lower collagen density i. Increasingly,
transcatheter replacement is being used to address mitral valve disease in high-risk patients with existing
annuloplasty rings or prosthetic valves. ViR procedures appear to have higher complication rates
compared with ViVii. Unlike the prosthetic valves which are circular, annuloplasty rings have an oval
configuration, built to fit the native mitral annulus. Therefore, the difficulty with ViR arises from this
mismatch of a round structure in a non-round hole, resulting in suboptimal apposition. Patients with rigid,
incomplete rings are at highest risk compared to those with flexible or semi-rigid, complete rings, which
are more easily deformed.
PVL following ViV or ViR transcatheter procedures can develop between the deployed valve and the
surgical ring (intervalvular) or between the ring and the native annulus (dehiscence). Mechanisms for the
former include inadequate valve expansion, relative atrial position of the valve (where the skirt of the
transcatheter valve lies above the annulus), or inappropriate sizing. Management options for intervalvular
leaks include balloon post-dilation or placement of a second valve in a more ventricular position (valve-
in-valve)iii. Management options for dehiscence include percutaneous closure device or open surgical
intervention, depending on the size of the orifice.
As technology improves and indications expand, we can expect an increase in catheter-based mitral
valvular interventions. Although a rare complication, PVL can occur after surgical mitral valve repair and
should be investigated prior to further procedures, which could worsen the leak. TEE plays a critical role
in the diagnosis and management of such complications.
Figure 1. 3D TEE image with color Doppler demonstrating trace PVL at the posterior aspect of the annuloplasty ring, pre-
deployment of Sapien transcatheter heart valve
Figure 2. 3D TEE image with color Doppler showing severe PVL after deployment of Sapien valve (valve-in-ring)
Figure 3. 3D TEE image with color Doppler showing placement of Amplatzer closure device
Figure 4. 3D TEE image with color Doppler demonstrating mild PVL after Amplatzer closure device at the valve-in-ring
References
i
Noack T, Kiefer P, Vivell N, Sieg F, Marin-Cuartas M, Leontyev S, Holzhey DM, Garbade J, Pfannmueller B,
Davierwala P, Misfeld M, Seeburger J, Borger MA. Annuloplasty ring dehiscence after mitral valve repair: incidence,
localization and reoperation. Eur J Cardiothorac Surg. 2019 Aug 1. pii: ezz219.
ii
Murdoch DJ, Sathananthan J, Cheung A, Webb JG. Combined transapical valve-in-valve/valve-in-ring
transcatheter mitral valve implantation and paravalvular leak closure for failed mitral valve surgery. Canadian
Journal of Cardiology. 2018 Aug 1;34(8):1088-e3.
Urena M, Himbert D, Brochet E, Carrasco JL, Iung B, Nataf P, Vahanian A. Transseptal transcatheter mitral
iii
valve replacement using balloon-expandable transcatheter heart valves: a step-by-step approach. JACC:
Cardiovascular Interventions. 2017 Oct 2;10(19):1905-19.

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Crushing the Pringle: Worsening Paravalvular Leak Following Mitral Valve-in-Ring

Yuanting Zha, MD, MPH; David M. Buric, MD; Adam S. Weinstein, MD

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