Techniques and Outcomes for the Treatment of Paravalvular Leak.

Abstract

Paravalvular prosthetic regurgitation is a potentially serious condition resulting from degeneration of annular tissue, affecting 6% to 15% of surgically implanted prosthetic valves and annuloplasty rings.1–3 In conditions of tissue friability from any cause, annular calcification, or infection, paravalvular defects can form and lead to varying degrees of regurgitation. Surgical factors associated with the development of paravalvular regurgitation include prostheses in the mitral position, supra-annular aortic prostheses, use of continuous sutures in the mitral position,3 and use of sutures without pledgets.4 Paravalvular defects are often crescentic and irregular in shape and may follow a serpiginous track from the downstream to upstream chamber. Chronic paravalvular mitral and aortic regurgitation can lead to left ventricular (LV), left atrial (LA) volume, and pressure overload, resulting in clinical heart failure. Because of noncompliance of the receiving chamber, the volume of regurgitation needed to induce symptoms may be relatively modest, such that standard volumetric measurements of regurgitation severity may not be applicable. In addition, conventional measures of mitral regurgitation severity such as the proximal isovelocity surface area method or pulmonary venous Doppler lack validation in this setting. Secondary elevation in pulmonary arterial pressure may result in right-sided heart failure. Paravalvular regurgitation is the most common cause of hemolytic anemia in patients with prosthetic heart valves. Increased red blood cell shear stress because of turbulent flow through the defect causes mechanical trauma and red blood cell fragmentation. Clinically significant hemolysis is more common in smaller defects with high-velocity jets, in patients with increased red blood cell fragility because of iron and folate deficiency, and in those with preexisting anemia because of the increased turbulence occurring from reduced blood viscosity and increased cardiac output. Moderate to severe paravalvular leak (PVL) after both surgical and transcatheter aortic valve replacement is associated with increased …