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            "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; New York Heart Association functional class before and after percutaneous closure attempt&#59; &#40;B&#41; severity of paravalvular leak &#40;Wilcoxon signed rank test&#41;&#46; NYHA&#58; New York Heart Association&#46;</p>"
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    "titulo" => "Imaging techniques&#58; Paving the way for paravalvular leak closure"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The present editorial refers to the article on paravalvular leak &#40;PVL&#41; closure by Galrinho et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> The authors report a single-center experience in a retrospective review and analyze possible predictors of success&#46; They performed 33 percutaneous PVL closures in 26 patients&#46; All mitral and aortic prostheses were studied previously with three-dimensional &#40;3D&#41; transesophageal echocardiography &#40;TEE&#41;&#46; 3D TEE and fluoroscopy were used for the assessment&#44; planning&#44; and guidance of the interventions&#46; In 12 patients they also performed computed tomography angiography &#40;CTA&#41; for better characterization&#46; Closure was successful in 17 patients &#40;65&#46;4&#37;&#41;&#44; partially successful in four &#40;15&#46;4&#37;&#41; and unsuccessful in five &#40;19&#46;2&#37;&#41;&#46; There was a relationship between clinical improvement and reduction of PVL &#40;p&#61;0&#46;0001&#41;&#46; In the follow-up&#44; cardiac-related events were more frequent in patients with partially successful or unsuccessful closure&#44; and there was a relationship between cardiac-related events and death&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">PVL is a not uncommon complication after surgical or transcatheter valve replacement that can develop years after the intervention&#46; About 1-5&#37; of PVLs lead to serious consequences&#44; including hemolytic anemia and congestive heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> Symptomatic PVLs are known to increase morbidity and mortality among patients with implanted prosthetic valves&#46; Traditionally&#44; surgical reintervention has been considered the gold standard for symptomatic patients with PVLs&#46; However&#44; it is associated with high morbidity and mortality&#44; and the percutaneous option has emerged as a less invasive alternative&#46; The surgical options are PVL repair or prosthesis replacement&#44; depending on the size and extent of the PVL&#44; the condition of the native valve&#44; and the patient&#39;s clinical history&#46; In some studies&#44; surgical management of PVLs shows better technical success rates than transcatheter techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> Nevertheless&#44; there is a higher risk of mortality and morbidity following redo cardiac surgery for PVL&#46; In addition&#44; after repeated surgeries&#44; there is a considerable risk of PVL recurrence due to tissue friability&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The percutaneous approach emerged initially as an alternative to medical treatment for inoperable patients or those at high surgical risk&#44; but for many experienced centers it has become the first-line therapy for patients with PVL&#46; The use of modern software &#40;especially with 3D TEE and CTA&#41; can improve outcomes&#46; Fusion technology&#44; which integrates ultrasound images with fluoroscopy for procedural guidance&#44; has also simplified the percutaneous procedures of transcatheter PVL closure&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although high technical success rates in percutaneous closure of PVLs are reported in multiple small series&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7&#44;8</span></a> there is a paucity of data on both acute and long-term outcomes in this group of patients&#46; Some studies suggest that successful percutaneous reduction of the PVL to mild or less is associated with significant mid-term survival benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">One of the strengths of percutaneous treatment of PVLs is the low rate of procedural complications &#40;since it is less invasive than the surgical option&#41;&#44; even in unsuccessful procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> Furthermore&#44; the percutaneous option does not exclude the possibility of future surgical interventions&#46; Technology has evolved&#44; imaging has improved and transcatheter techniques have advanced&#44; as has operator experience&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">However&#44; sometimes transcatheter procedures are not completely successful&#44; which leads to a higher risk of hospitalizations and worse functional class during follow-up&#44; but does not necessarily increase mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> In fact&#44; successful treatment of PVL through transcatheter techniques is associated with the same risk of death at three years of follow-up as that of surgically managed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> Improving results of PVL closure is based on thorough planning of the procedure with the available imaging technology&#46; It is known that a satisfactory technical result leads to a better prognosis&#46; In this regard&#44; in the article by Galrinho et al&#46;&#44; only 46&#37; of the patients had previous CTA &#40;12 of 26 patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> CTA can help to localize the PVL and provide a better assessment of its size&#44; which when measured on CTA correlates with the regurgitant grade on echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> In addition&#44; fusion of CTA and fluoroscopy data enables visualization of soft tissue structures and creates targets that move with the <span class="elsevierStyleSmallCaps">C</span>-arm&#44; facilitating the procedure&#46; Fusion imaging can help by guiding PVL closure and providing dynamic targets as an overlay on live fluoroscopy&#44; reducing the time needed for wire cannulation across the PVL and procedural time&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the absence of randomized studies&#44; the evidence shows that transcatheter techniques are an effective and safe option&#46; They should be considered the treatment of choice in experienced centers&#44; using all the available technology for improving results&#44; including imaging techniques that can help in the planning of the procedure&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Editorial comment
Imaging techniques: Paving the way for paravalvular leak closure
Técnicas de imagem: solidificar o caminho para o encerramento de fugas paravalvulares
Ana Pardo Sanz, José Luis Zamorano
Autor para correspondência
zamorano@secardiologia.es

Corresponding author.
Cardiology Department. University Hospital Ramon y Cajal, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The present editorial refers to the article on paravalvular leak &#40;PVL&#41; closure by Galrinho et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span>&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> The authors report a single-center experience in a retrospective review and analyze possible predictors of success&#46; They performed 33 percutaneous PVL closures in 26 patients&#46; All mitral and aortic prostheses were studied previously with three-dimensional &#40;3D&#41; transesophageal echocardiography &#40;TEE&#41;&#46; 3D TEE and fluoroscopy were used for the assessment&#44; planning&#44; and guidance of the interventions&#46; In 12 patients they also performed computed tomography angiography &#40;CTA&#41; for better characterization&#46; Closure was successful in 17 patients &#40;65&#46;4&#37;&#41;&#44; partially successful in four &#40;15&#46;4&#37;&#41; and unsuccessful in five &#40;19&#46;2&#37;&#41;&#46; There was a relationship between clinical improvement and reduction of PVL &#40;p&#61;0&#46;0001&#41;&#46; In the follow-up&#44; cardiac-related events were more frequent in patients with partially successful or unsuccessful closure&#44; and there was a relationship between cardiac-related events and death&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">PVL is a not uncommon complication after surgical or transcatheter valve replacement that can develop years after the intervention&#46; About 1-5&#37; of PVLs lead to serious consequences&#44; including hemolytic anemia and congestive heart failure&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">2</span></a> Symptomatic PVLs are known to increase morbidity and mortality among patients with implanted prosthetic valves&#46; Traditionally&#44; surgical reintervention has been considered the gold standard for symptomatic patients with PVLs&#46; However&#44; it is associated with high morbidity and mortality&#44; and the percutaneous option has emerged as a less invasive alternative&#46; The surgical options are PVL repair or prosthesis replacement&#44; depending on the size and extent of the PVL&#44; the condition of the native valve&#44; and the patient&#39;s clinical history&#46; In some studies&#44; surgical management of PVLs shows better technical success rates than transcatheter techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">3</span></a> Nevertheless&#44; there is a higher risk of mortality and morbidity following redo cardiac surgery for PVL&#46; In addition&#44; after repeated surgeries&#44; there is a considerable risk of PVL recurrence due to tissue friability&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The percutaneous approach emerged initially as an alternative to medical treatment for inoperable patients or those at high surgical risk&#44; but for many experienced centers it has become the first-line therapy for patients with PVL&#46; The use of modern software &#40;especially with 3D TEE and CTA&#41; can improve outcomes&#46; Fusion technology&#44; which integrates ultrasound images with fluoroscopy for procedural guidance&#44; has also simplified the percutaneous procedures of transcatheter PVL closure&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Although high technical success rates in percutaneous closure of PVLs are reported in multiple small series&#44;<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">7&#44;8</span></a> there is a paucity of data on both acute and long-term outcomes in this group of patients&#46; Some studies suggest that successful percutaneous reduction of the PVL to mild or less is associated with significant mid-term survival benefit&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">One of the strengths of percutaneous treatment of PVLs is the low rate of procedural complications &#40;since it is less invasive than the surgical option&#41;&#44; even in unsuccessful procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a> Furthermore&#44; the percutaneous option does not exclude the possibility of future surgical interventions&#46; Technology has evolved&#44; imaging has improved and transcatheter techniques have advanced&#44; as has operator experience&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">However&#44; sometimes transcatheter procedures are not completely successful&#44; which leads to a higher risk of hospitalizations and worse functional class during follow-up&#44; but does not necessarily increase mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> In fact&#44; successful treatment of PVL through transcatheter techniques is associated with the same risk of death at three years of follow-up as that of surgically managed patients&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> Improving results of PVL closure is based on thorough planning of the procedure with the available imaging technology&#46; It is known that a satisfactory technical result leads to a better prognosis&#46; In this regard&#44; in the article by Galrinho et al&#46;&#44; only 46&#37; of the patients had previous CTA &#40;12 of 26 patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a> CTA can help to localize the PVL and provide a better assessment of its size&#44; which when measured on CTA correlates with the regurgitant grade on echocardiography&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> In addition&#44; fusion of CTA and fluoroscopy data enables visualization of soft tissue structures and creates targets that move with the <span class="elsevierStyleSmallCaps">C</span>-arm&#44; facilitating the procedure&#46; Fusion imaging can help by guiding PVL closure and providing dynamic targets as an overlay on live fluoroscopy&#44; reducing the time needed for wire cannulation across the PVL and procedural time&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the absence of randomized studies&#44; the evidence shows that transcatheter techniques are an effective and safe option&#46; They should be considered the treatment of choice in experienced centers&#44; using all the available technology for improving results&#44; including imaging techniques that can help in the planning of the procedure&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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