Closure of prosthetic paravalvular leaks: a long way to go

Abstract

Cardiac valve replacement, albeit a well-established and safe procedure, is associated with a significant risk of complications. Symptomatic paravalvular leak (PVL) is a significant post-operative complication of cardiac valve replacement. The prevalence of this complication along with the long-term significance of asymptomatic leaks remains unknown. When these patients develop worsening heart failure or severe haemolysis that requires multiple transfusions from paravalvular regurgitation, the current recommendation is for closure of the leak. The recommended approach has been surgical closure until transcatheter techniques were introduced by Hourihan et al .1 There have been significant innovations in occlusive devices over the past 20 years; however, there are no specifically designed device(s) for the treatment of PVLs. Percutaneous device closure of PVLs has become an attractive alternative to surgical closure. This has further been enhanced by the ability to integrate multi-imaging modalities that have helped to define the pre-operative anatomy as well as to plan and guide the percutaneous closure procedure, resulting in improved outcomes. Since no single imaging modality has the capability to provide all the crucial information that is required for percutaneous closure of PVLs, in our centre we utilize an integrated multiple imaging modalities within a bi-plane cardiac catheterization laboratory. The following modalities assist in the assessment and guidance of percutaneous closure of PVLs. ### Echocardiography Echocardiography is a multifaceted tool used for the diagnosis, quantification, and guidance of treatment of paravalvular prosthetic valve leaks. ### Diagnosis Two-dimensional (2D) echocardiography with spectral and colour Doppler flow images are frequently used for the non-invasive diagnosis of PVLs. Transthoracic echocardiography (TTE) in various imaging planes obtained from the parasternal, apical, subxyphoid, and suprasternal windows helps to define the site of the leak ( Figure 1A ). However, the jet of prosthetic valvular and/or PVL may be overshadowed by the prosthetic valve, thus underestimating the degree of leak …