Citation, DOI & article data
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
Treatment and prognosis
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:
- 1. Rajiah P, Moore A, Saboo S et al. Multimodality Imaging of Complications of Cardiac Valve Surgeries. Radiographics. 2019;39(4):932-56. doi:10.1148/rg.2019180177 - Pubmed
- 2. Fanous E, Mukku R, Dave P et al. Paravalvular Leak Assessment: Challenges in Assessing Severity and Interventional Approaches. Curr Cardiol Rep. 2020;22(12):166. doi:10.1007/s11886-020-01418-7 - Pubmed
- 3. Ruiz C, Hahn R, Berrebi A et al. Clinical Trial Principles and Endpoint Definitions for Paravalvular Leaks in Surgical Prosthesis. J Am Coll Cardiol. 2017;69(16):2067-87. doi:10.1016/j.jacc.2017.02.038 - Pubmed
- 4. Hell M & Achenbach S. CT Support of Cardiac Structural Interventions. BJR. 2019;92(1098):20180707. doi:10.1259/bjr.20180707 - Pubmed
- 5. Lancellotti P, Pibarot P, Chambers J et al. Recommendations for the Imaging Assessment of Prosthetic Heart Valves: A Report from the European Association of Cardiovascular Imaging Endorsed by the Chinese Society of Echocardiography, the Inter-American Society of Echocardiography, and the Brazilian Department of Cardiovascular Imaging†. Eur Heart J Cardiovasc Imaging. 2016;17(6):589-90. doi:10.1093/ehjci/jew025 - Pubmed