Percutaneous management of paravalvular leaks

Abstract

Paravalvular leak (PVL) is a complication that occurs in 5–17% of patients after surgical prosthetic valve implantation. Whereas PVLs can be benign, some PVLs are associated with substantial morbidity and mortality. Percutaneous closure using occluders specifically designed to improve closure and reduce procedural complications has now become the first-line treatment for PVL. In this Review, we first detail the frequency and clinical consequences of PVL closure. The role of cardiac imaging in the assessment and management of PVL, including echocardiographic imaging and adjunctive techniques such as CT, is then discussed, together with important considerations for the percutaneous closure of PVL, such as access site and device selection. Finally, we summarize the clinical evidence for percutaneous closure of PVL, including large national registries from Ireland, Spain and the UK, as well as head-to-head data comparing this procedure with surgical closure.

Key points

  • Paravalvular leak (PVL) is an important complication of valve replacement surgery and is associated with substantial morbidity and mortality.

  • Evidence is emerging for the important role of percutaneous transcatheter closure as the first-line treatment for patients with PVL.

  • The role of imaging, particularly fluoroscopy and 3D transoesophageal echocardiography, is important in the assessment, planning and treatment of PVLs.

  • A structural heart team approach (with all relevant specialists) is critical for good clinical decision making for patients with PVLs.

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Fig. 1: PVL assessment in general and specialist cardiology clinics.
Fig. 2: Assessment of a mitral PVL.
Fig. 3: Assessment of an aortic PVL.
Fig. 4: Fusion of fluoroscopic and 3D transoesophageal echocardiography during closure of a mitral PVL.
Fig. 5: Devices for PVL closure.

Change history

  • 18 March 2019

    In the version of this article initially published online, the Paravalvular Leak Device (PLD; Occlutech) was incorrectly described as having a “proximal disc that is slightly larger than the distal disc”, whereas the distal disc is actually slightly larger than the proximal disc. This error has been corrected for the HTML, PDF and print versions of the article.

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Author information

J.P.G. researched data for the article and wrote the manuscript. B.S.R. produced the clinical images. All the authors provided substantial contribution to the discussion of content and reviewed and edited the manuscript before submission.

Correspondence to Patrick A. Calvert.

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