Paravalvular Leak Assessment: Challenges in Assessing Severity and Interventional Approaches

Abstract

Purpose of Review With increasing use of prosthetic valves to treat degenerative valvular heart disease (VHD) in an aging population, the incidence and adverse consequences of paravalvular leaks (PVL) are better recognized. The present work aims to provide a cohesive review of the available literature in order to better guide the evaluation and management of PVL. Recent Findings Despite gains in operator experience and design innovation, significant PVL remains a significant complication that may present with congestive heart failure and/or hemolytic anemia. To date, clear consensus or guidelines on the evaluation and management of PVL remain lacking. Summary Although the evolution of transcatheter valve therapies has had a tremendous impact on the management of patients with VHD, the limitations and complications of such techniques, including PVL, present further challenges. Incidence of PVL, graded as moderate or greater, ranges from 4 to 7.4% in surgical and transcatheter valve replacements, respectively. Improved imaging modalities and the advent of novel surgical and percutaneous therapies have undoubtedly yielded a better understanding of PVL including its anatomical location, mechanism, severity, and treatment options. Echocardiography, used in conjunction with cardiac computed tomography and cardiac magnetic resonance, provides essential details for diagnosis and management of PVL. Transcatheter intervention has become a favored approach in lieu of surgical intervention in select patients after previous surgical or percutaneous valve replacement. PVL treatment with vascular plugs, balloon post-dilation, and the valve-in-valve methods have shown technical success with promising clinical outcomes in appropriately selected patients.

The management of paravalvular leaks post aortic valve replacement.

“…Although there are benefits of using TTE, its use is restricted by shadowing seen on images, which may be caused by the prosthetic valve components or calcification of the annulus. The inaccurate imaging can result in the doppler signal having no colour ultimately resulting in underestimation of the severity of PVL and poor aetiology differentiation 9 . An example of a patient's scan with aortic PVL can be seen in Figure 1 10 .…”

“…In cases where both TTE and TEE cannot determine conclusively the grade or location of the PVL, cardiac CT can be used 9 . Cardiac CT is usually used as an imaging technique preoperatively for those who are due for TAVR; it can aid in verifying the annulus' size and shape and calcification degree 12 .…”

“…Cardiac CT involves the use for intravenous iodinated contrast agents which can potentially cause nephropathy 15 and anaphylactic shock (which is rare but serious life-threatening condition that requires urgent care) 16 . The patient will be exposed to radiation and poor resolution is seen in those with tachycardia 9 . There is also a need for a specialist radiologist report after a CT is performed which may be time consuming and that is not ideal in an emergency setting.…”

“…CMR can also be used in all patients especially when the TTE and TEE cannot conclusively predict the PVL degree or location in patients 9 . As mentioned previously, there is a risk of nephropathy when using CT in patients with renal failure.…”

“…Due to the components of the mechanical valve, CMR also provides a poor image with mechanical valves in comparison to bioprosthetic valves. In addition to this, the assessment accuracy is also affected by tachyarrhythmias 9 and presence of claustrophobia in some patients (usually due to the nature of the technique or the duration of the procedure) 19 In those who are claustrophobic, a relaxant such as diazepam could be used to obtain a successful image 19,20 .…”