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Resident PGY 2
Henry Ford Hospital
Introduction: Paravalvular leaks are a highly morbid complication of surgically replaced prosthetic valves of the heart. They often present with symptoms of decompensated heart failure, and patients can become dyspneic even at rest in severe cases. Oftentimes to repair the valve, patients are not surgical candidates due to their high risk of adverse events with re-sternotomy. Percutaneous repair of these valves has emerged as an effective and safe alternative to surgical management. There are limitations with percutaneous repair due to the inability to visualize the desired anatomy in a three-dimensional space. Some imaging modalities have helped bridge this gap, however here we report a case of a patient who had their left atrial appendage three-dimensionally printed to assist peri-procedurally with the repair of their valvular leak. Case: We are reporting the case of a 69 year old male with a past medical history of of severe aortic insufficiency with a history of a surgically replaced aortic valve in 2004, who presented with symptoms of shortness of breath, worsening with exertion. A standard transthoracic echocardiogram was conducted, identifying a large paravalvular leak of his mechanical aortic valve. He was a very high risk surgical candidate, and was thus referred to our structural heart team for percutaneous repair of his paravalvular leak. The patient originally underwent an attempted repair, however during the procedure we were unable to cross the defect in a retrograde fashion. A glidewire was able to be passed through however given the irregular shape of the actual defect, this wire was not supportive enough to deliver a catheter, and the procedure was terminated. He continued to follow up with our structural heart team, and the decision was made for the patient to undergo 3D CT imaging of his heart, with production and printing of a physical model of his left atrial appendage to assist peri-procedurally during a second attempt at the closure of the leak. At the second attempt of this percutaneous closure of his paravalvular leak one month later, successful closure of his paravalvular leak was achieved using a 6/4 ADO II device without any residual aortic insufficiency. The usage of a 3D printed model of the patients left atrial appendage helped our structural heart team evaluate the anatomy, cross the defect, and choose the appropriate device to plug the leak. He was successfully discharged from the hospital on post-op day 1, and did not have any readmissions to the hospital up to 6 months post-operatively. Discussion: Three-dimensional printing has enabled development of anatomical models for transcatheter planning among a variety of structural heart interventions. There have been very limited case reports involving using 3D printing to assist peri-procedurally in the planning and placement of devices to repair paravalvular leaks. Here we show the success of utilizing this method in a high risk case, with a patient that failed percutaneous repair of his valve using traditional imaging used for paravalvular leak repair. 3D printing enables the operator to physically grasp the structure, understand the anatomy from multiple points of view, and best understand which device to select. Navigating through a serpiginous course of defects and delivering the devices through small-bore sheaths and catheters utilizing the standard imaging techniques such as transesophageal echocardiography have remained sub-optimal due to limited standardized views and slow frame-rates. The advent of 3D printing may help bridge this gap moving forward. Cost will remain the biggest barrier to widespread implementation of this technology. However as the technology is further developed and improves, this will drive down the cost and allow further adoption. Further studies are needed to fully understand the benefits of 3D printing for paravalvular leak repairs, such as possibly reducing contrast exposure and operating time.
Fram, Georgi; Wang, Dee Dee; and Alrayes, Hussayn, "A Case of 3D Printing Shaping the Future of Percutaneous Cardiac Procedures" (2019). Case Reports. 47.