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Guiding and evaluation of specialities in interventional valve therapy - Course for modern transcatheter heart valve interventions

This session contained presentations about interventional paravalvular leak (PVL) closure, as well as tricuspid and pulmonary valve therapy. The session started with two presentations about PVL closure after surgical implantation of valvular prosthesis. The topic addressed by Nina Wunderlich was “Echocardiographic criteria of paravalvular leak: size, position and treatment indication”, while Christian Butter addressed the topic “Guiding during PVL procedures: how to evaluate success? When does closure cause deterioration of the patient’s condition?”.

Incidence of PVL is about 7-17% in mitral valve (MV) prosthesis and about 2-10% in aortic valve (AV) prosthesis. The indications for PVL closure are symptoms, intractable hemolysis and heart failure, as well as in high-risk surgical patients. Contraindications for PVL interventions are endocarditis, leaks > 1/3 of the circumference, early postoperative period, and an “ongoing process” of leakage formation. Location, size, number, distance and orientation of the leak with respect to the device ring of the prosthesis have to be evaluated by echocardiography, including the description of the leakage according to the “Watch” model. For preprocedural planning, TEE (2D/3D) or CT imaging should be used to localize the defects and to assess their number, size and shape . This is crucial for device selection and to determine the best approach. 3D TEE provides more accurate morphological information  than 2D echocardiography. During procedural guidance, 2D- and 3D TEE should be used in combination, to aim for a correct device position with sufficient reduction of PV leakage. Fusion imaging has the potential to facilitate procedures. For assessment post device deployment, 2D/3D TEE should again be used in combination to re-assess for proper device position, residual lesions and to re-confirm valve function.

Technical success can be defined as the correct deployment of an occlusive device through the PVL, and the lack of significant residual regurgitation or new prosthetic valve malfunction. Clinical success can be defined as a reduction of >1 grade on the New York Heart Association functional class scale and/or improvement in haemolytic anaemia (HA). The technical success rate is normally higher than the clinical success rate. Most patients with PVL present within the first year after valve replacement with symptoms of congestive heart failure (CHF) (85%), although hemolysis is also common (13–47% of patients). Indications for percutaneous closure of the PVL are clinical symptoms , intractable hemolysis or heart failure, as well as patients who are not candidates for reoperation or who are unwilling to undergo a reoperation. Absolute contraindications are signs of infection, endocarditis and dehiscence larger than 1/3 of circumference or if the prosthesis is tilting. Deterioration, however, can occur if implantation of a device was performed despite or after overlooking signs of infection or endocarditis, in the presence of too large leaks or if the prosthesis is tilting. The effect on hemolysis is often unpredictable. Sometimes, parameters of hemolysis increase after PVL intervention.

Next, the topic addressed by Ralph Stephan von Bardeleben was “The tricuspid valve: new approaches to treating right heart failure due to tricuspid regurgitation: how to guide the intervention by echocardiography?”. Transcatheter tricuspid valve therapy is a new approach to the forgotten valve. First attempts tried to separate the caval vein from the right atrium by implanting TAVI prostheses (CoreValve/DFM) to the inflow of the right atrium. TriAlign mimicked the Kaye procedure in folding the posterior tricuspid leaflet with a suture technique (CE mark trial). MitraClip classic and MitraClip NT have been used in a compassionate use model to treat tricuspid regurgitation, mainly by an Alfieri approach to the anterior and septal leaflet (about 120 patients worldwide). TRI repair (CE mark trial) is using the Cardioband annuloplasty approach to the tricuspid valve (8 patients worldwide). Thus, transcatheter tricuspid valve therapy seems feasible. Imaging is more complex than for the mitral valve. 3D imaging is a must in tricuspid regurgitation interventions. Echo/Fluoro Fusion can help in the orientation of anatomy and catheter positioning. Multiplanar reconstruction such as CT analysis or FlexiSlice are important approaches to these new valve procedures.

Finally, Ingo Daenert spoke about “The pulmonary valve: patient selection criteria in pulmonary stenosis and regurgitation for the interventional therapy – The role of echocardiography”. Percutaneous pulmonary valve interventions are indicated in GUCH patients with residual pulmonary stenosis and a right ventricular pressure > 66% LVP, free pulmonary regurgitation or pulmonary regurgitation > 33% (determined by MRI, a RVEDV > 150 ml/m²), significant LV dysfunction, progressive tricuspid regurgitation as well as arrhythmia requiring treatment. The role of echocardiography is described as being the routine imaging technique for follow-up investigations of all patients with native and repaired congenital heart disease. It is recommended that echocardiography be performed regularly in complex congenital heart disease without symptoms, typically at one year intervals. However, additional methods like CMR also have to be used. Contraindications to percutaneous pulmonary valve interventions in pulmonary valve disease are a right ventricular outflow tract that is too small (< 14mm) or too large (>28mm), structural tricuspid valve incompetence requiring surgery, other lesions requiring surgery, infective endocarditis, risk of coronary compression, as well as risk of uncontrolled conduit rupture. Thus, echocardiography is the main routine imaging modality for potential percutaneous pulmonary valve intervention candidates, and is mandatory in all patients prior to decision-making. It is sufficient for patient selection in predominant stenosis, but should be complemented by MRI in predominant regurgitation. It is the main imaging tool in follow-up and is mandatory in suspected infective endocarditis.

In summary, in this session, new approaches and techniques in specialities of intervalvular valve therapy were highlighted by up-to-date and attractive presentations.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.