Catheter-based closure of paravalvular leak

Abstract

Paravalvular leak (PVL) is a serious complication from surgical and percutaneous valve replacement procedures. The most common manifestations include congestive heart failure and hemolytic anemia, which may cause considerable morbidity and mortality. Repeat surgery for PVL closure is often complicated and carries a reduced probability of success. As such, catheter-based techniques to eliminate PVL have been developed. Percutaneous PVL closure procedures rely heavily on multimodality imaging techniques such as echocardiography, fluoroscopy and computed tomography for diagnosis, technical planning and procedural guidance. Evidence demonstrates that catheter-based closure of PVL boasts high procedural success rates and favorable clinical outcomes. Given the rapidly advancing nature of this field, this review summarizes the contemporary diagnosis of PVL, common techniques used for percutaneous closure and the latest data on patient outcomes following this procedure.

Keywords::

• aortic valve
• catheterization
• mitral valve
• paravalvular leak
• paravalvular regurgitation

Financial & competing interest disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Best estimates are that paravalvular leak (PVL) complicates approximately 1–5% of surgical aortic valve replacements, 2–12% of surgical mitral valve replacement and is more frequent after current generation transcatheter aortic valve replacement procedures.

• Symptoms of PVL include congestive heart failure and hemolysis, which are indications for intervention if medical management fails.

• Major risk factors for PVL after surgical valve replacement include those who have a mechanical valve placed, infective endocarditis, diffuse annular calcification and previous valve surgery in the same site.

• Multimodality imaging with transthoracic echocardiography, transesophageal echocardiography, intracardiac echocardiography, multidetector computerized tomography and fluoroscopy–computerized tomography fusion are important components in the proper diagnosis and treatment of PVL.

• There are no catheters or devices created specifically for PVL closure, and as such the devices are used off-label for this procedure.

• Techniques for percutaneous PVL closure include the transseptal, femoral and transapical approaches, with access site choice guided by the presence of other mechanical valves and need for additional wire support during the procedure.

• The most common occluder device used for PVL closure is the Amplatzer Vascular Plug II; however, other devices are often used at the discretion of the operator.

• Complications of percutaneous PVL closure include valve interference, heart block, device embolization, coronary ostia occlusion, pericardial effusion and hemothorax.

Notes