Percutaneous treatment of patients with heart diseases: selection, guidance and follow-up. A review
© Contaldi et al; licensee BioMed Central Ltd. 2012
Received: 10 January 2012
Accepted: 27 March 2012
Published: 27 March 2012
Aortic stenosis and mitral regurgitation, patent foramen ovale, interatrial septal defect, atrial fibrillation and perivalvular leak, are now amenable to percutaneous treatment. These percutaneous procedures require the use of Transthoracic (TTE), Transesophageal (TEE) and/or Intracardiac echocardiography (ICE). This paper provides an overview of the different percutaneous interventions, trying to provide a systematic and comprehensive approach for selection, guidance and follow-up of patients undergoing these procedures, illustrating the key role of 2D echocardiography.
Advances in cardiovascular interventional techniques have allowed percutaneous treatment of conditions that either previously required open operations or have not been amenable to any treatment.
Aortic stenosis (AS) is the most common valvular abnormality in the western world and it is more frequent in elderly patients with comorbidities. Transcatheter Aortic Valve Implantation (TAVI) offers an alternative to patients with severe symptomatic AS and contraindications for surgery or high risk for surgery .
Mitral regurgitation (MR) has a prevalence of 1-2% in the general population and there are several percutaneous techniques for the treatment of it, such as direct annuloplasty, indirect annuloplasty-coronary sinus and ventricular remodeling, however only repair by using Mitraclip has been extensively evaluated . Patent foramen ovale (PFO) and atrial septal defects (ASD) are interruption of atrial septum  and their percutaneous closure is a safe and accepted alternative to surgery [4–7].
Atrial fibrillation (AF) is the most common cardiac arrhythmias. At present, percutaneous left atrial appendage (LAA) occlusion may be an acceptable option in selected high-risk patients with AF who are not candidates to oral anticoagulation .
Para-valvular leaks (PVLs) represent a complication of cardiac valve replacement and their surgical repair is associated with a high mortality and morbidity rate, thus, in selected cases, percutaneous repair can be performed . This review emphasizes particularly the role of 2D echocardiography in selection, guidance and follow up of patients candidates to percutaneous treatment.
Transcatheter Aortic Valve Implantation TAVI
Diagnosis of AS
Indications to TAVI
To date, there is a lack of pharmacological therapies to prevent the progression of AS and unfortunately, balloon aortic valvuloplasty has revealed limited long-term efficacy .
Indications to TAVI
Severe AS with Symptoms
High Risk for Surgery
Life Expectancy < 1 Year
Severe Respiratory Insufficiency for Transapical Approach
Previous Surgery of the Left Ventricle using a Patch for Transapical Approach
18 < Aortic Annulus < 25 mm for SAPIEN Valve;
20 < Aortic Annulus < 27 mm for CORE Valve
Aortic Tubular Junction < 45 mm for CORE Valve
Bicuspid Aortic Valve
Height of coronary ostia from the base of aortic valve leaflets < 10 mm
Asymmetric Heavy Aortic Valvular Calcification
Mitral Regurgitation > 2+
Left Ventricular Ejection Fraction < 20%
Severe Left Ventricular Hypertrophy (< 1,7 cm)
Bulky Atherosclerosis of the Ascending Aorta and Arch for Transfemoral Approach
Calcified Pericardium for Transapical Approach
Echocardiography guidance of TAVI
Echocardiography is not mandatory to guide TAVI. Intraprocedural TEE may play a role with the SAPIEN series in guiding valve implantation and in early post implantation assessment . During the transapical approach, TEE is useful to evaluate MR, can increases because of worsening LV function, new wall motion abnormalities or dissyncrony induced by right ventricular pacing. The CoreValve is generally deployed under fluoroscopic guidance, with TEE being used on a discretionary basis, whereas post procedural AR is evaluated by aortography and TTE [1, 16]. Device malpositioning can cause severe paraprosthesic leak that can be managed successfully, in selected cases, with implantation of a second device inside the primary prosthesis (Valve-in-Valve procedure) .
Echocardiographic evaluation of TAVI complications and follow-up
Percutaneous MR repair with the MitraClip system
Diagnosis of MR
Indications to MitraClip system
Indications to MR Treatment by MitraClip System
MR 3+ or 4+
New Atrial Fibrillation
Recent Myocardial Infarction
Recent Surgical Procedure
Rheumatic Heart Disease
MR 3+ or 4+
Compromised Left Ventricular Function (EF < 60% or End-Systolic Diameter ≥ 40 mm)
A Regurgitant Jet Origin at Level of Coaptation Zone
Coaptation Length ≥ 2 mm
Coaptation Depth ≤ 11 mm
Flail Gap < 10 mm
Flail Width < 15 mm
Left Ventricular EF < 25%
Left Ventricular End-Systolic Diameter > 55 mm
Mitral Valve Orifice Area < 4 cm2
Echocardiography guidance of percutaneous MR with the MitraClip system
Echocardiographic evaluation of percutaneous MR with the MitraClip system Complications and follow-up
In the EVEREST I study, MitraClip had a low incidence of morbidity and mortality and reduction in MR (less than 2+) was observed in the majority of patients . There were no cases of clip embolization, whereas partial clip detachment was seen in 9% of patients; 11% of patients, with acute procedural success, underwent mitral valve surgery; within 1 year, 66% of patients had MR ≤ 2+, demonstrating durability of the percutaneous repair .
After percutaneous mitral valve repair, mitral valve area decreases without evidence of clinically significant mitral stenosis .
The EVEREST II is the first randomized trial which compares MitraClip device with open mitral valve surgery. Although percutaneous repair was less effective in to reducing MR than conventional surgery, it was associated with superior safety and similar improvements in clinical outcomes at 12 months .
TTE follow-up is recommended at 1 and 12 months .
Percutaneous closure of PFO and ASD
Diagnosis of PFO
Indications to percutaneous PFO closure
The prevalence of a PFO has been reported to be 24% in the general population and increases to 38% in patients with cryptogenic stroke, suggesting an association between PFO and stroke . Two prospective studies in the general population [43, 44] indicate that in healthy people with PFO, embolic events are not more frequent than in controls, therefore primary prevention and echocardiographic screening in asymptomatic patients are not needed . The AHA/ASA and ESO guidelines recommend antiplatelet agents for secondary prevention, while patients with hypercoagulable states or vein thrombosis should be anticoagulated [45–47], whereas when strokes recur, PFO closure is recommended; this comes true also for other high-risk patients, but guidelines leave the definition of "high risk" open .
Indications to PFO Closure
Migraine with Aura
Peripheral Venous Thrombosis
Previous History of Paradoxical Embolism
Severe Pulmonary Hypertension
Recent Gastrointestinal Bleeding
Controndications to Antiplatelet or Anticoagulant Therapy
Infection at the Time of Implantation
Atrial Septal Aneurysm
Large Size of PFO (≥ 4 mm)
Long Tunnel of PFO (≥ 1 cm)
Severe Right to Left Shunting (> 30 Bubles)
Shunting at Rest
Other Congenital Heart Defects
Eustachian valve and ChiariNetwork
Diagnosis of ASD
ASD is a common form of congenital heart disease accounting for approximately 10% of all congenital heart defects . There are four types of ASDs and the only ASD, at moment, susceptible to percutaneous closure is the secundum type .
Indications to percutaneous ASD closure
Indications to ASD Closure
Severe Pulmonary Hypertension
Recent Gastrointestinal Bleeding
Contraindications to Antiplatelet or Anticoagulant Therapy
Infection at the Time of Implantation
Qp/Qs ≥ 1,5
Right Atrial and/or Right Ventricular Enlargement
Other Congenital Heart Defects
ASD Diameter > 40 mm
Inadequate Septal Rims
Close Proximity to Coronary Sinus or Inferior Vena Cava
Echocardiography guidance of percutaneous PFO and ASD closure
Echocardiographic evaluation of PFO and ASD closure complications and follow-up
Percutaneous PFO and ASD closure is a safe and effective treatment in adults patients, even in case of thrombophilia or pulmonary hypertension, also during a long-term follow-up, up to 11 years [6, 7]. Early post-procedure complications, such as pericardial tamponade has been reported in approximately 0.5% to 1% of patients; tamponade most frequently results from LAA perforation during the trans-septal guide wire anchoring .
A early or late post-procedure relatively rare complication is device embolization . Residual shunts immediately after device closure of PFO/ASD, are common and often disappear or decrease, as the device endothelializes . However, if shunts persist, serial TTE evaluation must be performed to follow-up the degree of shunting .
Device thrombosis appears to be more common with devices containing uncoated metal arms, within the first month after device implantation . Finally, a late rare complication is severe mitral valve insufficiency, probably due to oversized mismatched device traction on the root of the mitral annulus and mitral annular insufficient rim .
During follow up, TTE is recommended at 6, 12 and 24 months .
Percutaneous closure of LAA in patients with AF
Echocardiography assessment of LA cavity and LAA in patients with AF
Indications to percutaneous LAA closure
Warfarin is the gold standard treatment to prevent embolic stroke, but benefits of anticoagulation do not come without risk of bleeding [62, 63] and, moreover, it is contraindicated in up to 44% of patients with AF .
Indications to LAA Percutaneous Closure
High Risk Patients with AF Not Candidates for Oral Anticoagulation
Patients with Recurrent Strokes Despite on Oral Anticoagulation
Recent Surgical Procedure
LAA Depth ≥ 10 mm
Active Endocarditis or Bacteriemia
Close Association of LAA with Mitral Valve, Pulmonary Veins and Circumflex Artery
Clinical and echocardiographic indications and contraindications to percutaneous LAA closure are reported in Table 5.
Echocardiography guidance of percutaneous LAA closure
Independently of the type of device, the actual deployment methodology is similar. First, standard transeptal puncture is performed for left atrial access. Next, the sheath is advanced up to the LAA orifice and a pigtail catheter is inserted into LAA. Then, TEE and fluoroscopic evaluate size (length and diameter), shape, and angulation of the orifice and body of the LAA. The device is then sized and is advanced into the LAA orifice .
Currently, three devices for LAA occlusion have been specifically designed: the Percutaneous LAA Transcatheter Occlusion (PLAATO), the WATCHMAN LAA system and Amplantzer Cardiac Plug Device. The PLAATO device was the first device, consisting of a self-expandible nitinol cage covered with a nonthrombogenic occlusive expanded polytetrafluoroethylene membrane and currently it is not available because of economic reasons. The WATCHMAN LAA System (Atritech, Plymouth, MN) consists of a parachute-shaped device with a self-expanding nitinol frame structure with a permeable polyester membrane over the atrial side and mid-perimeter fixation barbs to secure it in the LAA; it is permeable to blood, thus patients require conventional thromboembolic prophylaxis with 6 weeks of warfarin, at which time device endothelialization is confirmed by TEE . More recently, the Amplatzer Cardiac Plug (ACP)(AGA Medical) is a self-expanding flexible braided nitinol mesh structure designed as a distal lobe and a proximal disc linked via a flexible central waist [66, 67]; the lobe of the device is designed to conform to the inner wall of the LAA with a depth of 10 mm or more. For this device, TEE at 45°, measures the "landing zone" from the origin of left circumflex coronary artery to the roof of LAA, at least 10 mm below the ligament of Marshall (Figure 12, Panel B). The lobe of the device is anchored in the landing zone, 1-2 cm distal of the LAA orifice, while the disc fully covers the orifice of LAA. The size of the device should be at least 2 mm larger than the diameter of the LAA landing zone .
Echocardiographic evaluation of LAA closure complications and follow-up
To date, LAA percutaneous closure, in particularly with Amplatzer device, have proved to be a procedure with a high success rate (96%) and low rate of serious complications (7%) .
Percutaneous closure of PVLs
Diagnosis of PVLs
PVLs indicates a regurgitation between the prosthetic ring and the native valvular annulus [70–72] predisposed by endocarditis, annular calcification and redo operation for prosthesis malfunction .
Indications to percutaneous PVLs closure
Indications to PVLs Closure
Symptoms of Congestive Heart Failure in Patients Not Candidates for Surgery
Severe Hemolysis in Patients Not Candidates for Surgery
Severe Pulmonary Hypertension
Active Infection or Vegetations
Unstable Rocking Valve
Leaks Close to the Point of Maximum Leaflets Excursion
Echocardiographic guidance of PVLs percutaneous closure
Echocardiographic evaluation of PVLs closure complications and follow-up
PVLs percutaneous closure is a feasible procedure in selected patients, with a reasonable degree of technical and clinical success, complete or partial PVL occlusion in 70% of patients, with concomitant clinical improvements and an acceptable level of serious complications (10%) .
Early complications associated with device closure of PVLs include incomplete closure, impairment of valvular function, embolization and onset of new haemolysis .
A major limitation of perivalvular leak closure is the frequent persistence of leak, often due to the semilunar shape of the defects. In such cases, it may be prudent to plan a staged procedure, first implanting one device and after this has fibrosed, deploying another, rather than risking dislodgement or embolization of the first device with immediate implantation of a second [76, 79]. After the procedure, hemolysis may develop due to flow through the device, resolving with time as the device thromboses , or because a successful reduction in PVLs size, increases shear forces across the narrower orifice.
To ensure that device has not migrated, the leak has been closed follow-up with TTE is generally adequate at 1, 6 and 12 months.
Significant advances in percutaneous repair of many heart diseases have highlighted the importance of a systematic approach for selection, guidance and follow up of patients undergoing these procedures.
Echocardiography plays a critical role in patient selection, particularly in choosing the appropriate size of the prosthesis to be implanted. To date, TAVI is targeted at high-risk patients but it may be extended to the lower risk group in the future, if the initial promise holds true after careful evaluation.
A combination of TEE and supplemental TTE has been used for MitraClip procedure. Its safety profile is similar to other percutaneous procedures and now it is attractive for high-risk surgical candidates, in future randomized trial results will define the role for surgical candidates.
Understanding correlation between anatomy and echocardiography is perhaps the most essential requisite to ensure a successful PFO/ASD percutaneous closure procedure. The complication rates for both TEE and ICE imaging to guide this procedures appear to be low and acceptable, but ICE should be considered when suitable expertise is available. LAA percutaneous closure is an emerging approach and it, with appropriate patient selection, device iterations, and technical improvements, may become an important viable therapeutic alternative to chronic antithrombotic therapy. PVLs percutaneous closure is a new approach that can be useful for increasing PVLs because of increasing valve replacements. Appropriate designed devices for PVLs closure and improved imaging, particularly with ICE and with a wide use of 3D TEE, will help in this procedure. The echocardiography has an important and undeniable role. For the best result of percutaneous treatment, a close collaboration between sonographers and interventional cardiologists is required.
Written informed consent was obtained from the patient for publication of this report and any accompanying images.
American Heart Association/American College of Cardiology
American Heart Association/American Stroke Association
Atrial Septal Aneurysm
Atrial Septal Defects
Clip Delivery System
European Society of Cardiology
European Stroke Organisation
European System for Cardiac Operative Risk Evaluation
Endovascular Valve Edge-to-Edge Repair Study
Left Atrial Appendage
Left Ventricular Outflow Tract
Patent Foramen Ovale
Pulmonary Blood Flow
Systemic Blood Flow
- STS score:
Society of Thoracic Surgeons Cardiac Operative Risk Evaluation
Transcatheter Aortic Valve Implantation
- Valve in Valve procedure:
percutaneous implantation of a second device inside the primary percutaneous aortic prosthesis.
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