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Interventional management of paravalvular leak
  1. Mackram Eleid
  1. Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
  1. Correspondence to Dr Mackram Eleid, Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA; eleid.mackram{at}mayo.edu

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Learning objectives

  • Understand the clinical presentation and testing required for diagnosis of paravalvular leak.

  • Know the indications and contraindications for percutaneous paravalvular leak closure.

  • Be familiar with interventional techniques and outcomes for percutaneous paravalvular leak closure.

Introduction

Paravalvular leak (PVL) is a common and underdiagnosed condition affecting both surgical and transcatheter prosthetic heart valves.1–3 Characterised by a gap between the prosthetic valve and the native annular tissue, PVL results in regurgitation of blood from downstream to upstream chamber, occurring most often in conditions of tissue friability such as endocarditis, frailty, corticosteroid use, prior surgical valve replacement and/or in the setting of severe annular calcification. In transcatheter prosthetic valves, PVL occurs due to malapposition of the lower stent frame with the aortic annulus due to various factors including annular calcification, shape mismatch between annulus and prosthesis, prosthesis undersizing, prosthesis malposition or underexpansion.

Although mild PVL is usually asymptomatic, it can occasionally result in clinically significant haemolytic anaemia characterised by the need for blood transfusions, jaundice and/or choluria. More than mild PVL may result in symptoms of heart failure including dyspnoea, fatigue and secondary effects including pulmonary hypertension. In patients receiving transcatheter aortic valve replacement (TAVR), more than mild PVL is independently associated with higher mortality.4 5 The murmur of PVL is often soft in intensity on auscultation and prosthesis shadowing may obscure full detection with transthoracic echocardiography (TTE); for these reasons, a high index of suspicion is required to accurately diagnose PVL. More advanced detailed imaging modalities including transoesophageal echocardiography (TEE) and cardiac CT angiography (CTA) are essential tools to fully evaluate and characterise patients with suspected PVL.

When PVL is believed to be clinically significant, percutaneous PVL closure is indicated to improve quality of life and avoid the need for cardiac surgery.6 Recent studies have shown that successful PVL closure …

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