Application of 3D CT Image Guidance to Paravalvular Leak Repairs

Background
Paravalvular leaks (PVL) are highly morbid complications of prosthetic heart valve replacement. Frequently patients have multiple comorbidities and are at high or prohibitive risk for open surgical repair. Percutaneous PVL closure is a difficult procedure but can be performed with active guidance with transesophageal echocardiography (TEE) using a combination of two-dimensional (2D) and three-dimensional (3D) imaging. Pre-procedural planning with ECG gated 3D CT imaging of the heart is a novel technique that is increasingly being used in patients with high surgical risk, difficult anatomy, and prior failed percutaneous repair with standard TEE imaging.

Methods
Retrospective review of clinical outcomes of all patients who underwent 3D CT image guidance to assist in repairing paravalvular leaks of surgically implanted valves between February – December of 2017. Each patient underwent ECG gated 3D CT imaging and case planning along with 3D printing of the anatomic location of the PVL.

Results
Four patients were identified as having 3D CT imaging and 3D printing prior to percutaneous PVL closure. All patients were not felt to be surgical candidates. Two patients had aortic paravalvular leaks, and two had mitral paravalvular leaks. All patients had successful percutaneous closure of their PVL, with no peri-operative adverse events. One patient had a single readmission to the hospital due to heart failure up to 6 months post-op.

Conclusions
3D CT case analysis and 3D printed models are valuable in case planning for PVL closure by localizing defects, identification of landmarks and C-arm angles on fluoroscopy, navigating serpiginous defects, and in the selection of appropriate catheters and devices. This case planning can be used for both aortic or mitral PVL. Further study is required to fully understand benefits such as reducing contrast exposure and procedural time.