PMC9272523_01
Baseline two-dimensional (2D) X-plane imaging Transoeophageal Echocardiogram (TEE) color Doppler (A) and ascending aorta angiography (B) showing the presence of a huge crescent-shaped 17 x 6 mm aortic PVL located at non coronary cusp (NCC) 9-12 o'clock, with moderate-to-severe regurgitation. Fluoro-angiographic image confirming the stable position of the mechanical tilting disc aortic prosthetic valve (white asterisk) with moderate regurgitation (black arrow).
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F1
Both left and right femoral arteries were cannulated. 4-5 degree paravalvular aortic regurgitation was demonstrated by 2D TEE color Doppler and by ascending aortography with a 6-Fr pigtail angiographic catheter introduced from the left femoral artery (Figure 1). Intraprocedural 2D TEE color Doppler showed a persisting regurgitant jet via a 10 x 4 mm residual peri-device leakage probably due to the distorted "mushroom" spherical configuration of the two device disc and to elongated (up to 7 mm) shape of the connecting waist to fit the height of the original PVL (Supplementary Figure 1), hindering the apposition of the fabric within the disc.
Intraprocedural fluoro-angiographic and real-time 3D TEE procedural steps showing the guide wire (A) (black arrowhead) across the leakage with the distal soft tip in the left ventricle; the 5- Fr multipurpose catheter in the LV (B); the distal disc device opening (orange asterisk) (C-E) and the 14 x 6 mm rectangular waist PLD correctly positioned and still anchored to the delivery cable (F). MP, multipurpose catheter; PLD, Occlutech Parvalvular Leak Device; RW, rectangular waist.
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F2
The stronger support allowed progression of the 10-Fr delivery sheath into the LV. To accomplish the semilunar PVL dimensions (17 x 6 mm) with a height of 7 mm, a specifically designed 14 x 6 mm rectangular waist Paravalvular Leak Device (PLD, Occlutech, Helsingborg, Sweden) with a 24 mm distal disc, a 22 mm proximal disc and a 3 mm-height waist type of connection between the two disc was chosen and deployed (Figure 2). NYHA II class and good quality of life. No further hospitalizations and blood transfusions were needed. 2D TTE color Doppler confirmed the stable position of the two PLDs with trace residual leak (Supplementary Figure 2).
Fluoro-angiographic and real-time 3D TEE procedural steps showing the crossing of the residual leakage in close proximity of the already implanted 14 x 6 mm rectangular waist PLD (A-C), the distal disc opening of the 7 mm square twist PLD (D) still anchored to the delivery cable and the inference with the tilting disc of the mechanical aortic valve (E,F). RW, rectangular waist; ST, square twist.
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F3
PLD was then retrieved in the sheath and replaced by an undersized 5 mm square twist PLD that was implanted effectively without interfering anymore with the tilting disc of the mechanical aortic valve (Figure 3). Post-procedure echocardiographic and angiographic controls confirmed the effective PVL closure with only trivial residual regurgitant jet (Figure 4).
Post-procedure 2D TTE color Doppler (A) and fluoro-angiographic (B) images showing the correct and stable position of the two PLDs not impinging on the tilting disc (black arrowhead) of the mechanical aortic valve (white asterisk) with only trivial residual regurgitant jet.
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F4
PLD was then retrieved in the sheath and replaced by an undersized 5 mm square twist PLD that was implanted effectively without interfering anymore with the tilting disc of the mechanical aortic valve (Figure 3). Post-procedure echocardiographic and angiographic controls confirmed the effective PVL closure with only trivial residual regurgitant jet (Figure 4).