Interventional Management in Patients with Paravalvular Leaks

Paravalvular leak (PVL) closure is an increasingly frequently used procedure in structural intervention programs. Historical reviews suggest an incidence of PVL in the range of 1–2% after surgical valve replacement, and 2–20% after transcatheter aortic valve replacement. Heart failure and hemolysis may result from these leaks, and are the main indications for intervention. Reoperation is high risk since in all of these patients re-thoracotomies and redo operations would be needed; in addition, many of these patients have multiple co-morbidities. Percutaneous closure has developed as a therapy for this clinical condition. The use of three-dimensional transesophageal echocardiography and computed tomography has greatly facilitated the use of catheter methods to assess and treat PVL. Most PVL closure procedures are performed with both fluoroscopic and transesophageal echocardiographic imaging. It is usually difficult or even impossible to determine the site of a leak by angiography alone. Several different plug devices are used for these procedures. Most of these plugs are designed for general vascular use, with only a few designed especially for PVL closure. Catheter delivery is accomplished using trans-septal, retrograde aortic, and transapical approaches. Percutaneous closure of PVL improves both leak severity and symptoms. The technical challenges associated with PVL closure are numerous. Basic skills for crossing leaks with wires are substantial and often require a great deal of patience, flexibility, and a wide array of equipment. Percutaneous closure should be considered as an important alternative to repeat surgery associated with a high early mortality. Earlier leak closure prior to the onset of symptoms and signs of congestive heart failure or the development of hemolysis may ultimately achieve better outcomes of PVL closure.