Paravalvular Leak Closure With a Nonfenestrated Device

ercutaneous closure of paravalvular leaks (PVLs) has surpassed being merely an option for patients ineligible for surgery and now stands as the intervention of choice in the majority of cases, with outcomes that compare favorably to reoperation (1-3).The success of this technique depends on proper case selection, expert imaging guidance, and choice of a device that will minimize residual post-procedural PVL.In this issue of JACC: Case Reports, Cubeddu et al. (4) describe a case in which they offered symptomatic relief to an unwell patient with a large PVL after bioprosthetic mitral valve replacement by using the Cardioform Septal Occluder device (CSO, Gore Medical, Flagstaff, Arizona).PATHOPHYSIOLOGY OF PARAVALVULAR LEAKS Persistent PVLs after prosthetic valve replacement occur at a rate of 5% to 10% in the aortic position and 7% to 17% in the mitral position (5,6).A total of 4% to 6% of patients with PVL will present with symptoms (7), and the development of significant PVL is associated with poor clinical outcomes (8).Complications such as heart failure and hemolysis can arise and are independently associated with poor prognosis (5,9).PVLs tend to occur either because of malapposition of the prosthetic valve (most commonly from annular calcification mismatched with the round shape of the prosthesis) or because of failure of the valve's anchoring secondary to endocarditis or technical difficulties with suturing (with continuous sutures, uneven sutures, or improper suture tension) (10-12).Unlike defects in the atrial septum, both mitral and aortic PVLs encounter high (ventricular) pressures, and therefore even small openings can become a source of significant regurgitation.Furthermore, because blood is driven through these small channels at high pressure, hemolysis and transfusiondependent hemolytic anemia arise. AN EFFECTIVE APPROACH TO PARAVALVULAR LEAK CLOSUREWhen faced with a new patient requiring PVL closure, several steps are required to achieve a durable result in a safe and timely manner, as described here. CASE SELECTION.All interventions carry risk, and thus guideline-recommended indications should be adhered to ( 13):1.Heart failure with progressive left ventricular dysfunction 2. Hemolysis Clinical assessment, imaging, and laboratory studies are mandatory.Given the possibility that young, fit patients may receive a more durable result from reoperation, it is essential that a heart team approach is followed.The ratio of surgical to percutaneous treatment in a given center may vary with expertise, and percutaneous PVL closure can be challenging.PROCEDURAL PLANNING.