Multimodality imaging guidance for percutaneous paravalvular leak closure: Insights from the multicenter FFPP register

Background Percutaneous paravalvular leakages (PVL) closure has emerged as a palliative alternative to surgical management in selected high-risk patients. Percutaneous procedures are challenging especially for mitral PVL. An accurate imaging of the morphologies of the defects is mandatory together with a precise guiding in the catheterization laboratory to enhance success rate. Purpose We aimed to describe imaging modalities used in clinical practice to guide percutaneous PVL closure and assess the potential interest of new imaging tools. Methods Data from the FFPP (“Fermeture de Fuite paraprothetique”) register were used. The FFPP register is an international multi-institutional collaborative register started in 2017. A descriptive analysis of multimodality imaging used to guide PVL closure in clinical practice was performed. Results Data from 173 procedures performed in 19 centers from 3 countries (France, Belgium, Poland) were collected and included 8 cases of PVL following transcatheter valve replacement. Transesophageal echocardiography was used in 167 cases (96.5%) including 87.4% of cases with use of 3D-echocardiography. In one case 3D- echocardiography was combined and fused in real time with fluoroscopy images using echonavigator software. From a sample of 31 patients, details about multimodality imaging were available. Cardiac tomodensitometry (CT) was done before 10 procedures. In one case, fusion between pre-procedural cardiac CT angiography data and fluoroscopy data was used. In 2 cases, printing of a 3D model of the valve with PVL was done ( Fig. 1 ). Conclusion Echocardiography and in particular the 3D mode, is the cornerstone of paravalvular leakages imaging. Other imaging modalities such as cardiac computed tomography and cardiac magnetic resonance imaging may be of complementary interest. New techniques such as imaging fusion and printing may further facilitate the percutaneous approach of paravalvular leakages.