A paravalvular leak, paravalvular leakage or paravalvular regurgitation are an abnormal flow between the valvular annulus and the prosthetic heart valve and is a common complication after valvular replacement surgery due to inadequate sealing.
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Epidemiology
Paravaluvar leaks are common, with an estimated prevalence of 2-10% after aortic valve replacement and about 7-17% after mitral valve replacement 1-3.
Risk factors
Factors increasing the likelihood for paravalvular leaks include the following 3:
- annular calcification
- tissue friability
- prior infective endocarditis
- recent initiation of corticosteroid therapy
- valve type: mechanical valve > bioprosthetic implant
- valve position: supra-annular aortic valve > annular prosthesis
- technique: continuous suture > interrupted suture
Clinical presentation
Paravalvalvular leaks might present a complication, e.g. heart failure or hemolytic anemia or might be discovered on post-procedural imaging 2.
Complications
Complications of a paravalvular leak include the following conditions 1,2:
Pathology
Etiology
Causes of a paravalvular leak include the following 1,3:
- valvular dehiscence
- infective endocarditis
- resorption of annular calcification
- incorrect suturing of the valve to the annulus
Location
The most common site of aortic paravalvular leaks is around the non-coronary leaflet. In contrast, paravalvular leaks of the mitral valve are more commonly located in an anterolateral or a posteromedial position 3,4.
Radiographic features
Echocardiography
Echocardiography is considered the reference standard and first-line imaging modality for the assessment and can identify a paravalvular leak as a hypoechoic area, often with a crescentic or serpentine shape and flow on color Doppler outside the sewing ring of the prosthesis 1.
CT
Cardiac CT shows a contrast-filled channel outside the valve in the paravalvular region connecting the proximal and distal luminal area of the valve 1,4.
MRI
Cardiac MRI can show a separation of the sewing ring of the prosthetic valve and depict a paravalvular leak with dark dephasing artifacts in cine imaging and assess the orifice area 1.
Moreover, regurgitation can be quantified by phase-contrast MRI 1,3.
Radiology report
The radiological report should include a description of the following features 2,4:
- size and location in relation to anatomical landmarks
- shape and course
- regurgitant orifice
- annular calcifications
- regurgitant volume
Treatment and prognosis
Management of paravalvular leaks includes surgical repair and transcatheter approach for closure with a vascular plug or occluder 1-4.
Differential diagnosis
Conditions that can mimic the imaging appearance of a paravalvular leak include the following 1:
- paravalvular abscess
- pseudoaneurysm
- surgical pledget material