Response to: Reed GW, Tuzcu EM, Kapadia SR, Krishnaswamy A. Catheter-based closure of paravalvular leak. Expert. Rev. Cardiovasc. Ther. 12(6), 681–692 (2014).
In the review article by Reed et al. Citation[1], the authors review catheter-based closure techniques of paravalvular leaks (PVLs) as well as the devices used to treat them. The structural heart disease field has witnessed astounding success in percutaneous valve replacements in surgical and non-surgical candidates Citation[2]. However, valve replacements (percutaneous and open) have been plagued with complications such as PVLs due mainly to the sizing of the valve non-invasively (percutaneous valves) and to severe annular calcifications among other causes. PVLs are present more however in percutaneously replaced valves Citation[3]. PVLs have an incidence of 7–17% of mitral and 2–10% of aortic valve replacement. While the majority of PVLs is clinically benign, clinically significant PVLs occur in 1–5% of mitral valve replacements and aortic valve replacements Citation[4].
The assessment of PVLs should include various imaging modalities including Echocardiography, MRI and angiography specifically in cases when there is discrepancy in assessment of severity of PVLs among different modalities Citation[5–7]. The clinical importance of PVLs stems from the fact that they have a deleterious effect on ventricular function and survival; in patients with transcatheter aortic valve replacement, any PVL was shown to lead to increased mortality Citation[2]. Hence, the necessity of timely treatment of PVLs.
Given the increased mortality with reoperation to correct PVLs surgically, structural heart disease specialists improvised percutaneous techniques for PVL closure. Devices designed for treatment of patent ductus arteriosus, atrial or ventricular septal defects served as tools to close PVLs depending on location and size of the PVLs Citation[4].
Currently, all the treatment options are used off-label; however, we predict that there will be a revolution in innovation of better valve designs which will reduce the incidence of PVLs. In addition, devices designed to treat PVLs specifically are expected to appear in the structural cardiology landscape. However, multiple hurdles exist in the road to innovation of devices specifically geared to close PVLs including the ill-defined nature of PVLs anatomy, and the lack of monetary incentives given the limited load of patients Citation[4]. Despite all the difficulties however, the structural heart disease world will not stop to amaze us with exciting new breakthroughs.
Financial & competing interests 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.
References
- Reed GW, Tuzcu EM, Kapadia SR, Krishnaswamy A. Catheter-based closure of paravalvular leak. Expert Rev Cardiovasc Ther 2014;12(6):681-92
- Kodali SK, Williams MR, Smith CR, et al. Two-year outcomes after transcatheter or surgical aortic-valve replacement. N Engl J Med 2012;366(18):1686-95
- Genereux P, Head SJ, Hahn R, et al. Paravalvular leak after transcatheter aortic valve replacement: the new Achilles’ heel? A comprehensive review of the literature. J Am Coll Cardiol 2013;61(11):1125-36
- McElhinney DB. Will there ever be a food and drug administration-approved device for transcatheter paravalvular leak closure? Circ Cardiovasc Interv 2014;7(1):2-5
- Lerakis S, Hayek SS, Douglas PS. Paravalvular aortic leak after transcatheter aortic valve replacement: current knowledge. Circulation 2013;127(3):397-407
- Lerakis S, Hayek S, Arepalli CD, et al. Cardiac magnetic resonance for paravalvular leaks in post-transcatheter aortic valve replacement. Circulation 2014;129(14):e430-1
- Hayek S, Sawaya F, Oshinski J, Lerakis S. Multiparametric assessment of post-transcatheter aortic valve repacement paravalvular regurgitation grading by transthoracic echocardiography and cardiac magnetic resonance. J Clin Exp Cardiolog 2014;5:291