Periprocedural echocardiographic guidance for transcatheter paravalvular leak closure: from patient selection to follow-up

Paravalvular leak (PVL) after surgical valve replacement may cause heart failure, hemolytic anemia, or both. Transcatheter closure is an important therapeutic option for selected patients at high surgical risk. The irregular and often complex anatomy of PVL requires imaging assessment throughout patient selection, procedural planning, device deployment, and follow-up.Transthoracic echocardiography assesses prosthetic valve function and the hemodynamic consequences of PVL. Transesophageal echocardiography, particularly three-dimensional imaging with color Doppler, characterizes defect anatomy and guides wire crossing, device positioning, and release decisions. Assessment must address residual regurgitation, device stability, and potential interference with prosthetic valve function.Therapeutic goals depend on the dominant clinical phenotype. In heart failure-dominant PVL, sufficient reduction of regurgitant burden may improve symptoms and hemodynamics despite a small residual leak. In hemolysis-dominant PVL, residual high-velocity jets may sustain hemolysis and require additional closure. Mixed presentations require assessment of both hemodynamic and hematologic responses.Cardiac computed tomography complements echocardiography by defining channel geometry and fluoroscopic working projections, particularly when acoustic shadowing limits visualization. This review summarizes periprocedural echocardiographic assessment, emphasizing the integration of anatomical findings, clinical phenotype, and treatment response to guide procedural decisions and follow-up.