Transcatheter closure of paravalvular leaks – How do i do it?

Paravalvular leak following mitral and aortic valve replacement is a serious clinical problem, though fortunately rare.1 Even though immediate post-operative transesophageal echocardiographic studies have identified minute suture leaks in as many as 20%, hemodynamically significant leaks occur only in 1–5% of patients.2 They are commoner in mitral than aortic positions, but the incidence is highest with the recent transcatheter aortic valve implantations. The causes include improper suturing, undue stress on the suture lines across the annulus, fibrosis or calcification of the annulus which fails to hold the sutures and rarely infections.3 The patients present with anemia, hyperbilirubinemia, heart failure, or ventricular dysfunction with elevations of pro-brain natriuretic peptide levels.4,5 In this issue, Sasikumar et al have reported successful device closure of paravalvular leak following aortic valve replacement after balloon sizing their defects under transesophageal echocardiographic guidance.6 After balloon sizing, they employed sequential placement of two devices through the same leak through two femoral arterial sheaths. In another article in this same issue, Vinay kumar sharma et al have demonstrated the utility of trans esophageal three dimensional echo while closing the mitral para valvular leak.7 These two articles show the diversity of the nature of the leaks, presentation, and choice of devices, methods of deployment and guidance of the procedure. In this review, we intend to discuss the magnitude of the problem, justification for closure of paravalvular leak, technical details of the procedure, armamentarium of devices, important do's and don'ts and finally practical tips of successful completion of the procedure.