Mitral Paravalvular Leak: Clinical Implications, Diagnosis and Management

Figures

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  Figure 1. Central Illustration. Diagnostic flow chart. Diagnosis starts with clinical suspicion. TTE and TEE should be performed to confirm the diagnosis and correct characterization. Finally, CMR and CT can be used in special situations.

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  Figure 2. TTE PVL. Mitral regurgitation is detected. It must be noted that it is difficult to quantify the exact proportion of the flow in both planes due to artifacts as acoustic shadow. (A): 4-chamber image showing a mitral PVL with colour Doppler. (B): 3-chamber with acustic shadoiw in the left atrium and an anterior regurgigant jet of a PVL leak.

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  Figure 3. Mitral TEE. (A,B): regurgitation jet more severe that we could see at TTE on figure (A); (C): Truevue with colour Doppler.

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  Figure 4. Localization of mitral PVL. (A): Clockwise format. Surgeon’s view. TEE from the same patients; we can see the presence of two anterolateral leaks, at 9 and 10 h, and one septal leak at 3 h. (B): mitral and aortic drawing of clockwise format and interactions between different hearts structures—adapted from reference [2].

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  Figure 5. CT–fluoroscopy fusion for mitral PVL closure.

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  Figure 6. 3D printing in preprocedural planning of paravalvular leak closure. (A,B). 3D echocardiography images of the PVL. (D,E) 3D echocardiography images showing the result after percutaneous closure. (C,F) show the 3D model of the PVL and how it colud be closed with the device.

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  Figure 7. PVL closure devices. (a): Amplatzer Muscular VSD Occluder. (b): Amplatzer Duct Occluder. (c): Amplatzer Vascular Plug III. (d): Occlutech PLD (square-shaped design). (e): Amplatzer Septal Occluder. (f): Amplatzer Vascular Plug II. (g): Amplatzer Vascular Plug IV. (h): Occlutech PLD (rectangular-shaped design).

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  Figure 8. Anterograde approach. (A): Hydrophilic guidewire passes through the PVL and gets into aorta. (B): Guidewire is snared from an arterial access to complete the arteriovenous loop. (C): The delivery sheath crosses the PVL. (D): The device is delivered, and it does not interfere with the mechanical prosthesis.

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  Figure 9. Retrograde approach. AL1: Amplatz Left catheter; LA: left atrium; LV: left ventricle; MPV: mitral prosthetic valve; TEE: transoesophageal echocardiography.

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  Figure 10. Transapical approach using CT–fluoroscopy fusion.