Paravalvular leak

Last revised by Dr Joachim Feger on 17 Dec 2021

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.

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.

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

Paravalvalvular leaks might present a complication, e.g. heart failure or hemolytic anemia or might be discovered on post-procedural imaging 2.

Complications of a paravalvular leak include the following conditions 1,2:

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

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.

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.

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.

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.

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

Management of paravalvular leaks includes surgical repair and transcatheter approach for closure with a vascular plug or occluder 1-4.

Conditions that can mimic the imaging appearance of a paravalvular leak include the following 1:

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