Percutaneous closure of periprosthetic paravalvular leaks: A viable alternative to surgery? | Revista Portuguesa de Cardiologia (English edition)

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(A) A cleft-shaped paravalvular leak (PVL) (white arrow); (B) guidewire positioned in the PVL (white arrow); (C) a circular PVL (white arrow); (D) closure device correctly positioned in the PVL (white arrow)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Isabel Azevedo, Pedro Braga, Alberto Rodrigues, Lino Santos, Bruno Melica, José Ribeiro, Francisco Sampaio, Ricardo Fontes-Carvalho, Marlene Fonseca, Adelaide Dias, Vasco Gama Ribeiro" "autores" => array:11 [ 0 => array:2 [ "nombre" => "Ana Isabel" "apellidos" => "Azevedo" ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Braga" ] 2 => array:2 [ "nombre" => "Alberto" "apellidos" => "Rodrigues" ] 3 => array:2 [ "nombre" => "Lino" "apellidos" => "Santos" ] 4 => array:2 [ "nombre" => "Bruno" "apellidos" => "Melica" ] 5 => array:2 [ "nombre" => "José" "apellidos" => "Ribeiro" ] 6 => array:2 [ "nombre" => "Francisco" "apellidos" => "Sampaio" ] 7 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Fontes-Carvalho" ] 8 => array:2 [ "nombre" => "Marlene" "apellidos" => "Fonseca" ] 9 => array:2 [ "nombre" => "Adelaide" "apellidos" => "Dias" ] 10 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama Ribeiro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204917302015" "doi" => "10.1016/j.repce.2016.12.019" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302015?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117303864?idApp=UINPBA00004E" "url" => "/08702551/0000003600000078/v1_201707241250/S0870255117303864/v1_201707241250/en/main.assets" ] ] "itemSiguiente" => array:20 [ "pii" => "S2174204917301630" "issn" => "21742049" "doi" => "10.1016/j.repce.2017.06.002" "estado" => "S300" "fechaPublicacion" => "2017-07-01" "aid" => "1019" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "dis" "cita" => "Rev Port Cardiol. 2017;36:495-7" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3082 "formatos" => array:3 [ "EPUB" => 160 "HTML" => 2412 "PDF" => 510 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Editorial comment" "titulo" => "Percutaneous closure of prosthetic paravalvular leaks – Should it be considered the first therapeutic option?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "495" "paginaFinal" => "497" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Encerramento percutâneo de leaks periprotésicos – deve ser considerada como a primeira opção terapêutica?" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 958 "Ancho" => 2447 "Tamanyo" => 223436 ] ] "descripcion" => array:1 [ "en" => "Examples of devices used for percutaneous paravalvular leak closure: (1) Amplatzer Vascular Plug II; (2) Amplatzer Vascular Plug III; (3) Amplatzer Vascular Plug IV; (4) Amplatzer Duct Occluder; (5) Amplatzer Muscular VSD Occluder; (6) Amplatzer Septal Occluder; (7) Occlutech PLD (square); (8) Occlutech PLD (rectangular)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Marco Costa" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Marco" "apellidos" => "Costa" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S0870255117303876" "doi" => "10.1016/j.repc.2017.05.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117303876?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917301630?idApp=UINPBA00004E" "url" => "/21742049/0000003600000078/v1_201707290050/S2174204917301630/v1_201707290050/en/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S2174204917302003" "issn" => "21742049" "doi" => "10.1016/j.repce.2017.07.001" "estado" => "S300" "fechaPublicacion" => "2017-07-01" "aid" => "1037" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "simple-article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "edi" "cita" => "Rev Port Cardiol. 2017;36:487-8" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 1986 "formatos" => array:3 [ "EPUB" => 191 "HTML" => 1455 "PDF" => 340 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "Editorial" "titulo" => "2016: A historic year for the Portuguese Journal of Cardiology" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "487" "paginaFinal" => "488" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "2016: Um ano histórico para a Revista Portuguesa de Cardiologia" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 876 "Ancho" => 1545 "Tamanyo" => 45008 ] ] "descripcion" => array:1 [ "en" => "Developments in the Portuguese Journal of Cardiology's impact factor." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Lino Gonçalves" "autores" => array:1 [ 0 => array:2 [ "nombre" => "Lino" "apellidos" => "Gonçalves" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S087025511730519X" "doi" => "10.1016/j.repc.2017.07.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S087025511730519X?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302003?idApp=UINPBA00004E" "url" => "/21742049/0000003600000078/v1_201707290050/S2174204917302003/v1_201707290050/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "Original Article" "titulo" => "Percutaneous closure of periprosthetic paravalvular leaks: A viable alternative to surgery?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "489" "paginaFinal" => "494" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Isabel Azevedo, Pedro Braga, Alberto Rodrigues, Lino Santos, Bruno Melica, José Ribeiro, Francisco Sampaio, Ricardo Fontes-Carvalho, Marlene Fonseca, Adelaide Dias, Vasco Gama Ribeiro" "autores" => array:11 [ 0 => array:4 [ "nombre" => "Ana Isabel" "apellidos" => "Azevedo" "email" => array:1 [ 0 => "ana.isabel.az@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Pedro" "apellidos" => "Braga" ] 2 => array:2 [ "nombre" => "Alberto" "apellidos" => "Rodrigues" ] 3 => array:2 [ "nombre" => "Lino" "apellidos" => "Santos" ] 4 => array:2 [ "nombre" => "Bruno" "apellidos" => "Melica" ] 5 => array:2 [ "nombre" => "José" "apellidos" => "Ribeiro" ] 6 => array:2 [ "nombre" => "Francisco" "apellidos" => "Sampaio" ] 7 => array:2 [ "nombre" => "Ricardo" "apellidos" => "Fontes-Carvalho" ] 8 => array:2 [ "nombre" => "Marlene" "apellidos" => "Fonseca" ] 9 => array:2 [ "nombre" => "Adelaide" "apellidos" => "Dias" ] 10 => array:2 [ "nombre" => "Vasco" "apellidos" => "Gama Ribeiro" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Vila Nova de Gaia, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Encerramento percutâneo de regurgitações periprotésicas: uma alternativa viável à cirurgia?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 967 "Ancho" => 1333 "Tamanyo" => 76120 ] ] "descripcion" => array:1 [ "en" => "Study group profile. Eighteen patients were referred for percutaneous PVL closure at our center. Sixteen patients underwent a single procedure and two a second procedure, in a total of 20 procedures. Fifteen procedures were successful: 14 PVL closures in mitral prostheses (eight in biological and six in mechanical mitral valves) and one in a biological aortic prosthesis. PVL: paravalvular leak." ] ] ] "textoCompleto" => "IntroductionParavalvular leak (PVL) is an uncommon but potentially serious complication after prosthetic valve implantation. PVLs consist of an abnormal communication between two cardiac chambers adjacent to a prosthetic valve and manifest as a regurgitant jet originating between the outer margin of the prosthetic valve and the native tissue surrounding it. They may be due to abnormal pressure or traction forces on the prosthesis after surgery, and several factors are known to increase the risk of PVL, including annular calcification, infection, suturing technique, size and shape of the prosthetic implant and tissue friability. Early PVL is usually related to technical aspects of the surgical implant, whereas late PVL commonly results from suture dehiscence caused by endocarditis or the gradual resorption of incompletely debrided annular calcifications.<a class="elsevierStyleCrossRefs" href="#bib0045">1,2</a>The incidence of PVL is estimated to be 2-10% after surgical aortic valve replacement and 7-17% after mitral valve replacement. Most PVLs are asymptomatic, but in 1-5% of cases they have severe clinical consequences, with symptoms of congestive heart failure (CHF), hemolysis, or both.<a class="elsevierStyleCrossRefs" href="#bib0045">1,3</a>Until recently, surgery was the standard treatment, despite the high morbidity and mortality associated with reoperation. Alternatives to surgical closure of PVLs have been pursued over the years and in 1992 the first report on percutaneous PVL closure was presented, proving that the principles of percutaneous techniques to close intracardiac shunts could be translated to percutaneous PVL closure.<a class="elsevierStyleCrossRefs" href="#bib0045">1,2,4</a> Since then, percutaneous approaches to PVL closure have been developed as a less invasive strategy, through transseptal, apical left ventricular or retrograde arterial access, and a number of series have been published, with high rates of procedural success and favorable clinical outcomes.<a class="elsevierStyleCrossRef" href="#bib0065">5</a>This study reports our experience with this technique, aiming to review the efficacy and safety of percutaneous device closure in a consecutive series of patients with clinically significant PVL referred to our center.MethodsDefinitionsPVL was defined as a regurgitant jet originating between the outer margin of the prosthetic sewing ring and surrounding native tissues, demonstrated by Doppler echocardiography. CHF was defined as symptoms of heart failure consistent with New York Heart Association (NYHA) functional class of II or higher, and symptomatic hemolysis as hemolytic anemia (hemoglobin <13 g/dl in men or <12 g/dl in women, lactate dehydrogenase ≥600 mg/dl, or haptoglobin ≤10 mg/dl) requiring blood transfusion and/or erythropoietin injections, without any other source of blood loss.<a class="elsevierStyleCrossRef" href="#bib0055">3</a>Technical success was defined as successful deployment of the closure device across the PVL without mechanical interference with the prosthesis or conversion to surgery. Clinical success was defined as an improvement of at least one NYHA functional class and/or an improvement in hemolysis, allowing the patient to become transfusion free.<a class="elsevierStyleCrossRef" href="#bib0055">3</a>Patient populationBetween January 2009 and November 2015, 18 patients were referred to our Centre for possible percutaneous PVL closure. Patient clinical characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The median age was 71 years (range 45-81) and 8 (44.4%) were male. Ten patients (55.6%) had one prosthetic valve, six (33.3%) had two and two patients (11.1%) had three prosthetic valves, in mitral, aortic and/or tricuspid position. The median time since surgical valve replacement was 47.5 months (range 1-1283 months). Most of the patients were hypertensive and had a history of paroxysmal or permanent atrial fibrillation. Five patients had a history of coronary artery disease and three had previously undergone coronary artery bypass grafting.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>All patients referred for percutaneous PVL closure were symptomatic, with CHF and/or hemolysis, and were considered at high surgical risk after assessment by the local heart team. CHF alone was the indication for PVL closure in six patients (33.3%), hemolysis in three (16.7%) and both in five patients (27.8%); three patients underwent percutaneous PVL closure after a moderate to severe PVL had been documented after surgery and in one of the patients the indication was not specified. Written informed consent was obtained for every patient. The procedures were performed in the catheterization laboratory, under general anesthesia.ImagingAll patients underwent pre-procedural transthoracic (TTE) and transesophageal (TEE) echocardiography for assessment of the morphology and function of the native and prosthetic heart valves. The degree of valvular regurgitation and/or stenosis was assessed by Doppler echocardiography, in accordance with the recommendations of the European Association of Cardiovascular Imaging.<a class="elsevierStyleCrossRefs" href="#bib0070">6,7</a> The size, location and shape of each PVL orifice was imaged, analyzed and measured (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Two-dimensional (2D) and real-time three-dimensional (3D) TEE, including live real-time, real-time 3D zoom and full volume acquisition, with or without color Doppler, were used in the planning and guidance of each procedure. The operator used the displayed images in order to select the approach and to guide the catheters and the device. Successful crossing of the defect was confirmed by 3D TEE (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).Paravalvular leak closure techniqueA transseptal approach was used for the closure of mitral PVLs (95.0% [19] of procedures), crossing the mitral leak from the left atrium to the left ventricle, through an anterograde entry (not crossing the aortic valve). An arteriovenous loop was not used. A retrograde approach (from the ascending aorta to the left ventricle) was used for closure of aortic PVLs. A transapical approach was not adopted during this period. Amplatzer®-type devices (AGA Medical, Plymouth, Minnesota) were used for PVL closure.Follow-upAt the end of the procedure all patients underwent echocardiographic study to assess the presence of residual leak and to exclude complications such as pericardial effusion, intracardiac thrombi or new intracardiac shunt. Clinical follow-up to assess NYHA functional class and need for blood transfusion was performed in all patients.Statistical analysisClinical, echocardiographic and procedural data were obtained from retrospective review of patients’ records. The statistical analysis were performed using the SPSS statistical package (version 22.0, IBM SPSS, Chicago, Illinois). Continuous variables were reported as medians and range and categorical variables as numbers and percentage.ResultsThere were 20 procedures in 18 patients with leaks in biological valve prostheses (50.0%) and in mechanical valve prostheses (50.0%) (Video 1). Two patients underwent two procedures, both of which failed due to inability to cross the leak with the guidewire. One had a PVL in a mechanical mitral valve, while the other had two PVLs in a mitral bioprosthesis in septal position, one successfully closed with an Amplatzer® Duct Occluder device and another with an Amplatzer™ Vascular Plug device five months later. This was the only patient to receive two devices. Most of the PVLs closed were in mitral bioprostheses (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). There were 14 mitral PVLs treated in 13 patients (Video 2) and one aortic PVL treated in one patient.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Technical success was achieved in 75% (15) of the procedures. PVL closure failed in five interventions: two cases due to inability to cross the leak with the guidewire and three cases due to interference with the mechanical function of the prosthetic valve. The Amplatzer™ Vascular Plug III was used in nine (50.0%) patients and the Amplatzer™ Duct Occluder in two (11.2%). The Amplatzer™ Vascular Plug II, Amplatzer™ Muscular VSD Occluder and Amplatzer™ PDA closure device were used in one patient (5.6%) each. No device was implanted in four patients (22.2%). Median fluoroscopy time was 40.8 min for all procedures, 43.5 min (range 16.8-92.6) for mitral PVL closure and 28.4 min for aortic PVL closure. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of the interventions.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Technical and clinical successTechnical success was achieved in 75% (15) of the procedures (Video 3). Median NYHA functional class decreased by one after the procedure. Cases of hemolytic anemia decreased from seven (38.9%) pre-procedure to two (11.1%) at discharge. Two patients had minor bleeding at the femoral vascular access site. There were no arterial dissections, device embolizations, conversion to surgery or deaths related to the procedure. At six, 12 and 24 months, NYHA functional class and rate of hemolytic anemia remained stable. Four patients died during follow-up due to refractory CHF (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). Survival rates at six, 12 and 24 months were 77.8%, 77.8% and 61.1%, respectively.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>DiscussionSmall PVLs can be found on echocardiography in almost half of patients with prosthetic heart valves. In up to 5% of these patients, a larger leak with clinical significance may be apparent, most often associated with mitral valves, less often with aortic and rarely with tricuspid or pulmonary valves. Whether bioprostheses are associated with a greater risk of PVL than mechanical valves is still a matter of debate.<a class="elsevierStyleCrossRef" href="#bib0080">8</a>Clinical presentation may occur soon after surgery or years later, as documented by our experience. Symptoms may be due to the degree of regurgitation, leading to low effective cardiac output, CHF and/or hemolytic anemia, which arises from fragmentation of red blood cells in the high shear stress of the regurgitant jet. Primary or secondary infective endocarditis can also occur.<a class="elsevierStyleCrossRef" href="#bib0080">8</a>Spontaneous closure of PVLs is rare and medical treatment is largely palliative. Surgical correction has been the gold standard for treatment of PVL but is usually reserved for severely symptomatic patients and/or those with progressive cardiac dysfunction. The surgical mortality rate can be as high as 13% after the first procedure, in part due to the age and comorbidities of these patients, and in many symptomatic patients reoperation carries excessive risk and is usually not an option.<a class="elsevierStyleCrossRefs" href="#bib0055">3,8</a>Our experience demonstrates that percutaneous PVL closure can be a feasible treatment alternative in patients who are not candidates for surgery. As previously reported, percutaneous closure of PVL still faces several issues, particularly the lack of a specific device designed to treat PVL and hence off-label use of available devices; difficulty in crossing the leak due to the position or anatomical configuration of the defects, which can be serpiginous and/or rigid due to calcification of the annulus or to the valve annulus itself; and interference of the device with the function of the prosthetic valve, making it impossible to release the device.<a class="elsevierStyleCrossRefs" href="#bib0055">3,8</a> The operator's experience is crucial to the success of the intervention and may have accounted for our initial difficulties with this technique. The type of approach may also affect the final result, and a transapical approach may offer an alternative option in cases where transseptal or retrograde approaches are not feasible. The choice of device was at the discretion of the operator, based on echocardiographic and radiographic interpretation.Procedural and clinical success as well as complication rates were acceptable for these 18 high surgical risk patients. A team approach, including transesophageal echocardiography specialists, interventional and general cardiologists and anesthesiologists, facilitated these outcomes. Such interventions are lengthy, as demonstrated by the relatively long fluoroscopy times, and can be challenging and technically demanding; close cooperation between team members in preprocedural planning and during and after the intervention are therefore essential.Study limitations and future directionsThis was a retrospective study, subject to the limitations of this type of study. In addition, the relatively low number of patients included limits generalization of these results to a broader population.In the future, the inclusion of a larger number of patients and of procedures will be necessary in order to determine the predictors of technical success and of short- and long-term morbidity and mortality. The development of specific and more adaptive devices that can conform to a variety of shapes of these defects and the use of multimodality imaging in the planning and guidance of interventions is necessary in order to further improve the results of the technique.ConclusionsOur experience of PVL closure in a predominantly elderly, high-risk population was favorable in terms of technical success, clinical improvement and safety. The procedure is complex and a second intervention may be necessary.Percutaneous closure of PVLs may be a feasible and valid alternative treatment strategy for selected symptomatic patients refractory to medical therapy and at high surgical risk. A collaborative effort between a skilled interventional team can result in successful outcomes, apparently with lower morbidity and mortality rates in comparison to surgical series.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that no patient data is showed in this article.Right to privacy and informed consentThe authors declare that no patient data is showed in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres875764" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec863863" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres875763" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec863862" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Definitions" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Patient population" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Imaging" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Paravalvular leak closure technique" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Follow-up" ] 5 => array:2 [ "identificador" => "sec0040" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0045" "titulo" => "Results" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Technical and clinical success" ] ] ] 7 => array:3 [ "identificador" => "sec0055" "titulo" => "Discussion" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Study limitations and future directions" ] ] ] 8 => array:2 [ "identificador" => "sec0065" "titulo" => "Conclusions" ] 9 => array:3 [ "identificador" => "sec0070" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0075" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0080" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0085" "titulo" => "Right to privacy and informed consent" ] ] ] 10 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-06-19" "fechaAceptado" => "2016-12-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec863863" "palabras" => array:5 [ 0 => "Percutaneous intervention" 1 => "Perivalvular leak" 2 => "Valve prosthesis" 3 => "Aortic" 4 => "Mitral" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec863862" "palabras" => array:5 [ 0 => "Intervenção percutânea" 1 => "Regurgitação paravalvular" 2 => "Prótese valvular" 3 => "Aórtica" 4 => "Mitral" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "Introduction and ObjectivesParavalvular leak (PVL) is a possible complication after prosthetic valve implantation. PVL can cause significant symptoms of congestive heart failure and/or hemolysis. Medical therapy is palliative and reoperation has a high mortality rate. Percutaneous transcatheter closure is a promising alternative for symptomatic patients at high surgical risk. We aim to review the efficacy and safety of percutaneous PVL closure in a consecutive series of patients referred to our center. MethodsWe performed a retrospective analysis of clinical and technical procedural data of patients referred to our center for percutaneous PVL closure between January 2009 and November 2015. ResultsTwenty procedures were performed in 18 patients under general anesthesia and under transesophageal echocardiographic and radiographic guidance. Fourteen mitral PVLs were successfully treated in 13 patients and one aortic PVL in one patient. Most (eight) of the PVLs closed were in mitral bioprostheses. Two patients underwent a second intervention, which was technically successful in one. Technical success was achieved in 15 (75%) of the procedures. At discharge, median NYHA functional class decreased by one and hemolytic anemia decreased from seven cases (38.9%) to two (11.1%). Two patients had minor bleeding at the femoral vascular access site. Survival rates at six, 12 and 24 months were 77.8%, 77.8% and 61.1%, respectively. ConclusionsIn our experience, percutaneous PVL closure was overall effective and safe. The procedure is complex and a second intervention may be necessary. Percutaneous PVL closure may be a feasible alternative for selected symptomatic patients at high surgical risk refractory to medical therapy." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction and Objectives" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "Introdução e objetivosAs regurgitações paravalvulares (RPV) constituem uma complicação da cirurgia de substituição valvular. Em alguns casos podem surgir sintomas de insuficiência cardíaca congestiva e/ou hemólise. A terapêutica médica é paliativa e a reoperação associa-se a elevada taxa de mortalidade. O encerramento percutâneo poderá ser uma alternativa para doentes com elevado risco cirúrgico. Pretendemos rever a eficácia e segurança do encerramento percutâneo de RPV numa série de doentes consecutivamente referenciados ao nosso centro. MétodosAnálise retrospetiva de dados clínicos e dos procedimentos efetuados em doentes referenciados para encerramento percutâneo de RPV, de janeiro de 2009 a novembro de 2015. ResultadosVinte procedimentos foram efetuados em 18 doentes, sob anestesia geral, orientação radiológica e por ecocardiografia transesofágica. Foram tratadas 14 RPV mitrais com sucesso em 13 doentes e uma RPV aórtica. A maioria das RPV foram encerradas em biopróteses mitrais. Dois doentes foram submetidos a uma reintervenção, tecnicamente bem sucedida num deles. O sucesso técnico foi atingido em 15 (75%) dos procedimentos. À data de alta, a mediana de classe funcional NYHA diminuiu numa classe e a hemólise de sete (38,9%) para dois (11,1%) doentes. Dois doentes tiveram hemorragias minor nos locais dos acessos vasculares femorais. As taxas de sobrevivência aos seis, 12 e 24 meses foram 77,8, 77,8 e 61,1%, respetivamente. ConclusõesA nossa experiência foi globalmente eficaz e segura. O procedimento é complexo e uma reintervenção pode ser necessária. Esta técnica poderá constituir uma alternativa para doentes selecionados, sintomáticos, de elevado risco cirúrgico e refratários à terapêutica médica." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introdução e objetivos" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<elsevierMultimedia ident="upi0005"></elsevierMultimedia><elsevierMultimedia ident="upi0010"></elsevierMultimedia><elsevierMultimedia ident="upi0015"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary material" "identificador" => "sec0100" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1013 "Ancho" => 1500 "Tamanyo" => 188534 ] ] "descripcion" => array:1 [ "en" => "Three-dimensional transesophageal echocardiographic assessment. (A) A cleft-shaped paravalvular leak (PVL) (white arrow); (B) guidewire positioned in the PVL (white arrow); (C) a circular PVL (white arrow); (D) closure device correctly positioned in the PVL (white arrow)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 967 "Ancho" => 1333 "Tamanyo" => 76120 ] ] "descripcion" => array:1 [ "en" => "Study group profile. Eighteen patients were referred for percutaneous PVL closure at our center. Sixteen patients underwent a single procedure and two a second procedure, in a total of 20 procedures. Fifteen procedures were successful: 14 PVL closures in mitral prostheses (eight in biological and six in mechanical mitral valves) and one in a biological aortic prosthesis. PVL: paravalvular leak." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Data are presented as number (percentage) or median (range). CABG: coronary artery bypass grafting; KDOQI: Kidney Disease Outcomes Quality Initiative; NYHA: New York Heart Association." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 (44.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">71 (45-81) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time since valvular replacement (months) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">47.5 (1-1283) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of prosthetic valves \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (1-3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Comorbidities</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (50.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coronary artery disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (27.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prior CABG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (16.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (55.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">KDOQI stage ≥3 chronic kidney disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (11.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NYHA class \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">II (I-IV) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemolysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (38.9) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1478234.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "PVL: paravalvular leak. Data are presented as number (percentage) or median (range)." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Total no. of procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mitral PVLs to treat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mitral PVLs treated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 (72.2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mitral PVLs requiring second procedure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (11.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aortic PVLs to treat \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aortic PVLs treated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (100) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Approach</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transseptal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">19 (95.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Retrograde (transaortic) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (5.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Fluoroscopy time (min)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mitral PVL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">43.5 (16.8-92.6) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aortic PVL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">28.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Procedural failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inability to cross with guidewire \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (10.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Interference with function of prosthesis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (15.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Complications</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bleeding through vascular access \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (10.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1478236.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Procedural outcomes." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "CHF: congestive heart failure." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Gender \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of PVL \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Location of leak \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Successful PVL closure \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Cause of death \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Time after procedure (months) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Biological mitral valve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Anterolateral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" 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Original Article

Percutaneous closure of periprosthetic paravalvular leaks: A viable alternative to surgery?

Encerramento percutâneo de regurgitações periprotésicas: uma alternativa viável à cirurgia?

Ana Isabel Azevedo

Corresponding author

ana.isabel.az@gmail.com

Corresponding author.

, Pedro Braga, Alberto Rodrigues, Lino Santos, Bruno Melica, José Ribeiro, Francisco Sampaio, Ricardo Fontes-Carvalho, Marlene Fonseca, Adelaide Dias, Vasco Gama Ribeiro

Cardiology Department, Vila Nova de Gaia/Espinho Hospital Centre, Vila Nova de Gaia, Portugal

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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Study group profile&#46; Eighteen patients were referred for percutaneous PVL closure at our center&#46; Sixteen patients underwent a single procedure and two a second procedure&#44; in a total of 20 procedures&#46; Fifteen procedures were successful&#58; 14 PVL closures in mitral prostheses &#40;eight in biological and six in mechanical mitral valves&#41; and one in a biological aortic prosthesis&#46; PVL&#58; paravalvular leak&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Paravalvular leak &#40;PVL&#41; is an uncommon but potentially serious complication after prosthetic valve implantation&#46; PVLs consist of an abnormal communication between two cardiac chambers adjacent to a prosthetic valve and manifest as a regurgitant jet originating between the outer margin of the prosthetic valve and the native tissue surrounding it&#46; They may be due to abnormal pressure or traction forces on the prosthesis after surgery&#44; and several factors are known to increase the risk of PVL&#44; including annular calcification&#44; infection&#44; suturing technique&#44; size and shape of the prosthetic implant and tissue friability&#46; Early PVL is usually related to technical aspects of the surgical implant&#44; whereas late PVL commonly results from suture dehiscence caused by endocarditis or the gradual resorption of incompletely debrided annular calcifications&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The incidence of PVL is estimated to be 2-10&#37; after surgical aortic valve replacement and 7-17&#37; after mitral valve replacement&#46; Most PVLs are asymptomatic&#44; but in 1-5&#37; of cases they have severe clinical consequences&#44; with symptoms of congestive heart failure &#40;CHF&#41;&#44; hemolysis&#44; or both&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Until recently&#44; surgery was the standard treatment&#44; despite the high morbidity and mortality associated with reoperation&#46; Alternatives to surgical closure of PVLs have been pursued over the years and in 1992 the first report on percutaneous PVL closure was presented&#44; proving that the principles of percutaneous techniques to close intracardiac shunts could be translated to percutaneous PVL closure&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1&#44;2&#44;4</span></a> Since then&#44; percutaneous approaches to PVL closure have been developed as a less invasive strategy&#44; through transseptal&#44; apical left ventricular or retrograde arterial access&#44; and a number of series have been published&#44; with high rates of procedural success and favorable clinical outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This study reports our experience with this technique&#44; aiming to review the efficacy and safety of percutaneous device closure in a consecutive series of patients with clinically significant PVL referred to our center&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Definitions</span><p id="par0025" class="elsevierStylePara elsevierViewall">PVL was defined as a regurgitant jet originating between the outer margin of the prosthetic sewing ring and surrounding native tissues&#44; demonstrated by Doppler echocardiography&#46; CHF was defined as symptoms of heart failure consistent with New York Heart Association &#40;NYHA&#41; functional class of II or higher&#44; and symptomatic hemolysis as hemolytic anemia &#40;hemoglobin &#60;13 g&#47;dl in men or &#60;12 g&#47;dl in women&#44; lactate dehydrogenase &#8805;600 mg&#47;dl&#44; or haptoglobin &#8804;10 mg&#47;dl&#41; requiring blood transfusion and&#47;or erythropoietin injections&#44; without any other source of blood loss&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Technical success was defined as successful deployment of the closure device across the PVL without mechanical interference with the prosthesis or conversion to surgery&#46; Clinical success was defined as an improvement of at least one NYHA functional class and&#47;or an improvement in hemolysis&#44; allowing the patient to become transfusion free&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patient population</span><p id="par0035" class="elsevierStylePara elsevierViewall">Between January 2009 and November 2015&#44; 18 patients were referred to our Centre for possible percutaneous PVL closure&#46; Patient clinical characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The median age was 71 years &#40;range 45-81&#41; and 8 &#40;44&#46;4&#37;&#41; were male&#46; Ten patients &#40;55&#46;6&#37;&#41; had one prosthetic valve&#44; six &#40;33&#46;3&#37;&#41; had two and two patients &#40;11&#46;1&#37;&#41; had three prosthetic valves&#44; in mitral&#44; aortic and&#47;or tricuspid position&#46; The median time since surgical valve replacement was 47&#46;5 months &#40;range 1-1283 months&#41;&#46; Most of the patients were hypertensive and had a history of paroxysmal or permanent atrial fibrillation&#46; Five patients had a history of coronary artery disease and three had previously undergone coronary artery bypass grafting&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">All patients referred for percutaneous PVL closure were symptomatic&#44; with CHF and&#47;or hemolysis&#44; and were considered at high surgical risk after assessment by the local heart team&#46; CHF alone was the indication for PVL closure in six patients &#40;33&#46;3&#37;&#41;&#44; hemolysis in three &#40;16&#46;7&#37;&#41; and both in five patients &#40;27&#46;8&#37;&#41;&#59; three patients underwent percutaneous PVL closure after a moderate to severe PVL had been documented after surgery and in one of the patients the indication was not specified&#46; Written informed consent was obtained for every patient&#46; The procedures were performed in the catheterization laboratory&#44; under general anesthesia&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Imaging</span><p id="par0045" class="elsevierStylePara elsevierViewall">All patients underwent pre-procedural transthoracic &#40;TTE&#41; and transesophageal &#40;TEE&#41; echocardiography for assessment of the morphology and function of the native and prosthetic heart valves&#46; The degree of valvular regurgitation and&#47;or stenosis was assessed by Doppler echocardiography&#44; in accordance with the recommendations of the European Association of Cardiovascular Imaging&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6&#44;7</span></a> The size&#44; location and shape of each PVL orifice was imaged&#44; analyzed and measured &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Two-dimensional &#40;2D&#41; and real-time three-dimensional &#40;3D&#41; TEE&#44; including live real-time&#44; real-time 3D zoom and full volume acquisition&#44; with or without color Doppler&#44; were used in the planning and guidance of each procedure&#46; The operator used the displayed images in order to select the approach and to guide the catheters and the device&#46; Successful crossing of the defect was confirmed by 3D TEE &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Paravalvular leak closure technique</span><p id="par0055" class="elsevierStylePara elsevierViewall">A transseptal approach was used for the closure of mitral PVLs &#40;95&#46;0&#37; &#91;19&#93; of procedures&#41;&#44; crossing the mitral leak from the left atrium to the left ventricle&#44; through an anterograde entry &#40;not crossing the aortic valve&#41;&#46; An arteriovenous loop was not used&#46; A retrograde approach &#40;from the ascending aorta to the left ventricle&#41; was used for closure of aortic PVLs&#46; A transapical approach was not adopted during this period&#46; Amplatzer<span class="elsevierStyleSup">&#174;</span>-type devices &#40;AGA Medical&#44; Plymouth&#44; Minnesota&#41; were used for PVL closure&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Follow-up</span><p id="par0060" class="elsevierStylePara elsevierViewall">At the end of the procedure all patients underwent echocardiographic study to assess the presence of residual leak and to exclude complications such as pericardial effusion&#44; intracardiac thrombi or new intracardiac shunt&#46; Clinical follow-up to assess NYHA functional class and need for blood transfusion was performed in all patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Clinical&#44; echocardiographic and procedural data were obtained from retrospective review of patients&#8217; records&#46; The statistical analysis were performed using the SPSS statistical package &#40;version 22&#46;0&#44; IBM SPSS&#44; Chicago&#44; Illinois&#41;&#46; Continuous variables were reported as medians and range and categorical variables as numbers and percentage&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><p id="par0070" class="elsevierStylePara elsevierViewall">There were 20 procedures in 18 patients with leaks in biological valve prostheses &#40;50&#46;0&#37;&#41; and in mechanical valve prostheses &#40;50&#46;0&#37;&#41; &#40;Video 1&#41;&#46; Two patients underwent two procedures&#44; both of which failed due to inability to cross the leak with the guidewire&#46; One had a PVL in a mechanical mitral valve&#44; while the other had two PVLs in a mitral bioprosthesis in septal position&#44; one successfully closed with an Amplatzer<span class="elsevierStyleSup">&#174;</span> Duct Occluder device and another with an Amplatzer&#8482; Vascular Plug device five months later&#46; This was the only patient to receive two devices&#46; Most of the PVLs closed were in mitral bioprostheses &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; There were 14 mitral PVLs treated in 13 patients &#40;Video 2&#41; and one aortic PVL treated in one patient&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Technical success was achieved in 75&#37; &#40;15&#41; of the procedures&#46; PVL closure failed in five interventions&#58; two cases due to inability to cross the leak with the guidewire and three cases due to interference with the mechanical function of the prosthetic valve&#46; The Amplatzer&#8482; Vascular Plug III was used in nine &#40;50&#46;0&#37;&#41; patients and the Amplatzer&#8482; Duct Occluder in two &#40;11&#46;2&#37;&#41;&#46; The Amplatzer&#8482; Vascular Plug II&#44; Amplatzer&#8482; Muscular VSD Occluder and Amplatzer&#8482; PDA closure device were used in one patient &#40;5&#46;6&#37;&#41; each&#46; No device was implanted in four patients &#40;22&#46;2&#37;&#41;&#46; Median fluoroscopy time was 40&#46;8 min for all procedures&#44; 43&#46;5 min &#40;range 16&#46;8-92&#46;6&#41; for mitral PVL closure and 28&#46;4 min for aortic PVL closure&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the results of the interventions&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Technical and clinical success</span><p id="par0080" class="elsevierStylePara elsevierViewall">Technical success was achieved in 75&#37; &#40;15&#41; of the procedures &#40;Video 3&#41;&#46; Median NYHA functional class decreased by one after the procedure&#46; Cases of hemolytic anemia decreased from seven &#40;38&#46;9&#37;&#41; pre-procedure to two &#40;11&#46;1&#37;&#41; at discharge&#46; Two patients had minor bleeding at the femoral vascular access site&#46; There were no arterial dissections&#44; device embolizations&#44; conversion to surgery or deaths related to the procedure&#46; At six&#44; 12 and 24 months&#44; NYHA functional class and rate of hemolytic anemia remained stable&#46; Four patients died during follow-up due to refractory CHF &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Survival rates at six&#44; 12 and 24 months were 77&#46;8&#37;&#44; 77&#46;8&#37; and 61&#46;1&#37;&#44; respectively&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Small PVLs can be found on echocardiography in almost half of patients with prosthetic heart valves&#46; In up to 5&#37; of these patients&#44; a larger leak with clinical significance may be apparent&#44; most often associated with mitral valves&#44; less often with aortic and rarely with tricuspid or pulmonary valves&#46; Whether bioprostheses are associated with a greater risk of PVL than mechanical valves is still a matter of debate&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Clinical presentation may occur soon after surgery or years later&#44; as documented by our experience&#46; Symptoms may be due to the degree of regurgitation&#44; leading to low effective cardiac output&#44; CHF and&#47;or hemolytic anemia&#44; which arises from fragmentation of red blood cells in the high shear stress of the regurgitant jet&#46; Primary or secondary infective endocarditis can also occur&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Spontaneous closure of PVLs is rare and medical treatment is largely palliative&#46; Surgical correction has been the gold standard for treatment of PVL but is usually reserved for severely symptomatic patients and&#47;or those with progressive cardiac dysfunction&#46; The surgical mortality rate can be as high as 13&#37; after the first procedure&#44; in part due to the age and comorbidities of these patients&#44; and in many symptomatic patients reoperation carries excessive risk and is usually not an option&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Our experience demonstrates that percutaneous PVL closure can be a feasible treatment alternative in patients who are not candidates for surgery&#46; As previously reported&#44; percutaneous closure of PVL still faces several issues&#44; particularly the lack of a specific device designed to treat PVL and hence off-label use of available devices&#59; difficulty in crossing the leak due to the position or anatomical configuration of the defects&#44; which can be serpiginous and&#47;or rigid due to calcification of the annulus or to the valve annulus itself&#59; and interference of the device with the function of the prosthetic valve&#44; making it impossible to release the device&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3&#44;8</span></a> The operator&#39;s experience is crucial to the success of the intervention and may have accounted for our initial difficulties with this technique&#46; The type of approach may also affect the final result&#44; and a transapical approach may offer an alternative option in cases where transseptal or retrograde approaches are not feasible&#46; The choice of device was at the discretion of the operator&#44; based on echocardiographic and radiographic interpretation&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Procedural and clinical success as well as complication rates were acceptable for these 18 high surgical risk patients&#46; A team approach&#44; including transesophageal echocardiography specialists&#44; interventional and general cardiologists and anesthesiologists&#44; facilitated these outcomes&#46; Such interventions are lengthy&#44; as demonstrated by the relatively long fluoroscopy times&#44; and can be challenging and technically demanding&#59; close cooperation between team members in preprocedural planning and during and after the intervention are therefore essential&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Study limitations and future directions</span><p id="par0110" class="elsevierStylePara elsevierViewall">This was a retrospective study&#44; subject to the limitations of this type of study&#46; In addition&#44; the relatively low number of patients included limits generalization of these results to a broader population&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the future&#44; the inclusion of a larger number of patients and of procedures will be necessary in order to determine the predictors of technical success and of short- and long-term morbidity and mortality&#46; The development of specific and more adaptive devices that can conform to a variety of shapes of these defects and the use of multimodality imaging in the planning and guidance of interventions is necessary in order to further improve the results of the technique&#46;</p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Our experience of PVL closure in a predominantly elderly&#44; high-risk population was favorable in terms of technical success&#44; clinical improvement and safety&#46; The procedure is complex and a second intervention may be necessary&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Percutaneous closure of PVLs may be a feasible and valid alternative treatment strategy for selected symptomatic patients refractory to medical therapy and at high surgical risk&#46; A collaborative effort between a skilled interventional team can result in successful outcomes&#44; apparently with lower morbidity and mortality rates in comparison to surgical series&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ethical disclosures</span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Protection of human and animal subjects</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Confidentiality of data</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that no patient data is showed in this article&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Right to privacy and informed consent</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors declare that no patient data is showed in this article&#46;</p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicts of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Imaging"
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              "titulo" => "Paravalvular leak closure technique"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2016-06-19"
    "fechaAceptado" => "2016-12-01"
    "PalabrasClave" => array:2 [
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          "clase" => "keyword"
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          "identificador" => "xpalclavsec863863"
          "palabras" => array:5 [
            0 => "Percutaneous intervention"
            1 => "Perivalvular leak"
            2 => "Valve prosthesis"
            3 => "Aortic"
            4 => "Mitral"
          ]
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      ]
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          "clase" => "keyword"
          "titulo" => "Palavras-chave"
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          "palabras" => array:5 [
            0 => "Interven&#231;&#227;o percut&#226;nea"
            1 => "Regurgita&#231;&#227;o paravalvular"
            2 => "Pr&#243;tese valvular"
            3 => "A&#243;rtica"
            4 => "Mitral"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Paravalvular leak &#40;PVL&#41; is a possible complication after prosthetic valve implantation&#46; PVL can cause significant symptoms of congestive heart failure and&#47;or hemolysis&#46; Medical therapy is palliative and reoperation has a high mortality rate&#46; Percutaneous transcatheter closure is a promising alternative for symptomatic patients at high surgical risk&#46; We aim to review the efficacy and safety of percutaneous PVL closure in a consecutive series of patients referred to our center&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective analysis of clinical and technical procedural data of patients referred to our center for percutaneous PVL closure between January 2009 and November 2015&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Twenty procedures were performed in 18 patients under general anesthesia and under transesophageal echocardiographic and radiographic guidance&#46; Fourteen mitral PVLs were successfully treated in 13 patients and one aortic PVL in one patient&#46; Most &#40;eight&#41; of the PVLs closed were in mitral bioprostheses&#46; Two patients underwent a second intervention&#44; which was technically successful in one&#46; Technical success was achieved in 15 &#40;75&#37;&#41; of the procedures&#46; At discharge&#44; median NYHA functional class decreased by one and hemolytic anemia decreased from seven cases &#40;38&#46;9&#37;&#41; to two &#40;11&#46;1&#37;&#41;&#46; Two patients had minor bleeding at the femoral vascular access site&#46; Survival rates at six&#44; 12 and 24 months were 77&#46;8&#37;&#44; 77&#46;8&#37; and 61&#46;1&#37;&#44; respectively&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In our experience&#44; percutaneous PVL closure was overall effective and safe&#46; The procedure is complex and a second intervention may be necessary&#46; Percutaneous PVL closure may be a feasible alternative for selected symptomatic patients at high surgical risk refractory to medical therapy&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
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            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introdu&#231;&#227;o e objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">As regurgita&#231;&#245;es paravalvulares &#40;RPV&#41; constituem uma complica&#231;&#227;o da cirurgia de substitui&#231;&#227;o valvular&#46; Em alguns casos podem surgir sintomas de insufici&#234;ncia card&#237;aca congestiva e&#47;ou hem&#243;lise&#46; A terap&#234;utica m&#233;dica &#233; paliativa e a reopera&#231;&#227;o associa-se a elevada taxa de mortalidade&#46; O encerramento percut&#226;neo poder&#225; ser uma alternativa para doentes com elevado risco cir&#250;rgico&#46; Pretendemos rever a efic&#225;cia e seguran&#231;a do encerramento percut&#226;neo de RPV numa s&#233;rie de doentes consecutivamente referenciados ao nosso centro&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">An&#225;lise retrospetiva de dados cl&#237;nicos e dos procedimentos efetuados em doentes referenciados para encerramento percut&#226;neo de RPV&#44; de janeiro de 2009 a novembro de 2015&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Vinte procedimentos foram efetuados em 18 doentes&#44; sob anestesia geral&#44; orienta&#231;&#227;o radiol&#243;gica e por ecocardiografia transesof&#225;gica&#46; Foram tratadas 14 RPV mitrais com sucesso em 13 doentes e uma RPV a&#243;rtica&#46; A maioria das RPV foram encerradas em biopr&#243;teses mitrais&#46; Dois doentes foram submetidos a uma reinterven&#231;&#227;o&#44; tecnicamente bem sucedida num deles&#46; O sucesso t&#233;cnico foi atingido em 15 &#40;75&#37;&#41; dos procedimentos&#46; &#192; data de alta&#44; a mediana de classe funcional NYHA diminuiu numa classe e a hem&#243;lise de sete &#40;38&#44;9&#37;&#41; para dois &#40;11&#44;1&#37;&#41; doentes&#46; Dois doentes tiveram hemorragias <span class="elsevierStyleItalic">minor</span> nos locais dos acessos vasculares femorais&#46; As taxas de sobreviv&#234;ncia aos seis&#44; 12 e 24 meses foram 77&#44;8&#44; 77&#44;8 e 61&#44;1&#37;&#44; respetivamente&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A nossa experi&#234;ncia foi globalmente eficaz e segura&#46; O procedimento &#233; complexo e uma reinterven&#231;&#227;o pode ser necess&#225;ria&#46; Esta t&#233;cnica poder&#225; constituir uma alternativa para doentes selecionados&#44; sintom&#225;ticos&#44; de elevado risco cir&#250;rgico e refrat&#225;rios &#224; terap&#234;utica m&#233;dica&#46;</p></span>"
        "secciones" => array:4 [
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            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary material"
            "identificador" => "sec0100"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Three-dimensional transesophageal echocardiographic assessment&#46; &#40;A&#41; A cleft-shaped paravalvular leak &#40;PVL&#41; &#40;white arrow&#41;&#59; &#40;B&#41; guidewire positioned in the PVL &#40;white arrow&#41;&#59; &#40;C&#41; a circular PVL &#40;white arrow&#41;&#59; &#40;D&#41; closure device correctly positioned in the PVL &#40;white arrow&#41;&#46;</p>"
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        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Study group profile&#46; Eighteen patients were referred for percutaneous PVL closure at our center&#46; Sixteen patients underwent a single procedure and two a second procedure&#44; in a total of 20 procedures&#46; Fifteen procedures were successful&#58; 14 PVL closures in mitral prostheses &#40;eight in biological and six in mechanical mitral valves&#41; and one in a biological aortic prosthesis&#46; PVL&#58; paravalvular leak&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Data are presented as number &#40;percentage&#41; or median &#40;range&#41;&#46; CABG&#58; coronary artery bypass grafting&#59; KDOQI&#58; Kidney Disease Outcomes Quality Initiative&#59; NYHA&#58; New York Heart Association&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;44&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;years&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71 &#40;45-81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Time since valvular replacement &#40;months&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">47&#46;5 &#40;1-1283&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Number of prosthetic valves</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;1-3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Comorbidities</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;50&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Coronary artery disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;27&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prior CABG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atrial fibrillation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10 &#40;55&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>KDOQI stage &#8805;3 chronic kidney disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;11&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">NYHA class</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hemolysis</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">PVL&#58; paravalvular leak&#46; Data are presented as number &#40;percentage&#41; or median &#40;range&#41;&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Total no&#46; of procedures</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Mitral PVLs to treat</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mitral PVLs treated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13 &#40;72&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mitral PVLs requiring second procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;11&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Aortic PVLs to treat</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aortic PVLs treated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;100&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Approach</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Transseptal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">19 &#40;95&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Retrograde &#40;transaortic&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;5&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Fluoroscopy time &#40;min&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mitral PVL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">43&#46;5 &#40;16&#46;8-92&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aortic PVL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Procedural failure</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;25&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Inability to cross with guidewire&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Interference with function of prosthesis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;15&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Complications</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bleeding through vascular access&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;10&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of PVL&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biological mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anterolateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cardiogenic shock&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Biological mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anterolateral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Male&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mechanical mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Anteroseptal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Female&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mechanical mitral valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Medial&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">28&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Mortality at follow-up&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:8 [
            0 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "1"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Review of surgical prosthetic paravalvular leaks&#58; diagnosis and catheter-based closure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "C&#46; Kliger"
                            1 => "R&#46; Eiros"
                            2 => "G&#46; Isasti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehs347"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2013"
                        "volumen" => "34"
                        "paginaInicial" => "638"
                        "paginaFinal" => "648"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23117162"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2016.12.019

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Year/Month	Html	Pdf	Total

2024 November	7	3	10
2024 October	51	29	80
2024 September	57	28	85
2024 August	48	25	73
2024 July	29	28	57
2024 June	38	19	57
2024 May	44	25	69
2024 April	54	33	87
2024 March	40	26	66
2024 February	45	21	66
2024 January	43	37	80
2023 December	37	28	65
2023 November	44	28	72
2023 October	38	16	54
2023 September	44	17	61
2023 August	69	34	103
2023 July	70	14	84
2023 June	52	11	63
2023 May	91	32	123
2023 April	59	9	68
2023 March	68	26	94
2023 February	53	20	73
2023 January	38	18	56
2022 December	81	32	113
2022 November	91	27	118
2022 October	55	26	81
2022 September	32	44	76
2022 August	43	41	84
2022 July	54	45	99
2022 June	58	39	97
2022 May	50	39	89
2022 April	64	48	112
2022 March	49	46	95
2022 February	45	38	83
2022 January	38	30	68
2021 December	37	36	73
2021 November	53	44	97
2021 October	61	40	101
2021 September	47	30	77
2021 August	46	39	85
2021 July	35	12	47
2021 June	38	34	72
2021 May	56	47	103
2021 April	79	26	105
2021 March	48	35	83
2021 February	57	28	85
2021 January	37	9	46
2020 December	37	17	54
2020 November	42	18	60
2020 October	25	16	41
2020 September	60	16	76
2020 August	21	4	25
2020 July	45	14	59
2020 June	42	14	56
2020 May	54	10	64
2020 April	41	12	53
2020 March	38	18	56
2020 February	66	55	121
2020 January	29	7	36
2019 December	30	4	34
2019 November	17	7	24
2019 October	40	8	48
2019 September	31	15	46
2019 August	19	8	27
2019 July	33	7	40
2019 June	23	25	48
2019 May	32	10	42
2019 April	17	14	31
2019 March	39	11	50
2019 February	55	7	62
2019 January	45	9	54
2018 December	75	12	87
2018 November	105	17	122
2018 October	167	26	193
2018 September	77	14	91
2018 August	61	8	69
2018 July	20	4	24
2018 June	33	6	39
2018 May	34	13	47
2018 April	59	8	67
2018 March	47	11	58
2018 February	21	6	27
2018 January	34	8	42
2017 December	55	14	69
2017 November	37	18	55
2017 October	48	19	67
2017 September	50	36	86
2017 August	74	28	102
2017 July	3	1	4

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