Paravalvular Leak or PVL refers to a leak caused by a space between an implanted heart valve and the natural heart tissues around the valve. PVL can occur with surgical prosthetic valves ( mechanical or bioprosthetic) or transcatheter heart valves.
What does this mean for me?
Paravalvular leaks affect a small number of people after the implantation of a bioprosthetic or mechanical valve. Surgically implanted valves are usually placed without any gaps between the edges of the valve and are sutured to surrounding heart tissues. A gap can develop around the replacement valve over time. In general, small paravalvular leaks will not cause symptoms with the exception of a condition called hemolysis where red blood cells which pass through the leak at a high velocity are damaged causing anemia due to drop in blood cell counts. More significant leaks will lead to symptoms of heart failure, such as shortness of breath, swelling, abnormal heart beat (heart flutter and atrial fibrillation) and fatigue. These symptoms often worsen with exercise.
Symptoms: How would I know if I have a PVL?
In general small paravalvular leaks will not cause symptoms. Significant PVL can cause symptoms of heart failure. Small paravalvular leaks don’t necessarily cause symptoms of heart failure but can cause a rare type of anemia called hemolytic anemia, where red cells are damaged as they are shot through the hole at a high velocity.
Signs or symptoms can vary in severity and may include:
Unexplained weight gain
Swelling in your legs and feet
Feeling out of breath with low-exertion exercise
Difficulty breathing when lying flat in bed
Paleness of the skin
Feeling tired all the time
Reduced ability to do normal low-exertion activities
Symptoms will typically be worse with exercise. Even if you are not experiencing symptoms, you should follow up regularly with your cardiologist to check on your heart function.
Next Steps: Investigation Plan
During your visit with your doctor, he/she will be examining you for fluid retention, heart murmurs, and other signs to diagnose a significant paravalvular leak. Usually, a test called a Transthoracic Echocardiogram (TTE) which takes moving or still images of the internal parts of the heart using an ultrasound, will have been done which suggests a leak.
Sometime paravalvular leaks can be difficult to diagnose by a TTE. Even if a TTE is diagnostic, the physician will choose to do another test called a Transesophageal echocardiogram (TEE) to confirm the diagnosis. A TEE (2D or 3D) obtains very high-resolution images of the heart and is the gold standard for diagnosing paravalvular leaks. If a procedure is planned, you will almost always require a TEE with 3D views to assist in planning the procedure.
Treatment Options for PVL
Paravalvular leak is a mechanical problem and the only definitive treatment is to fix the hole. Surgical or transcatheter/ percutaneous closure for PVL is usually advised in severely symptomatic patients and in those that require blood transfusions for persisting hemolysis. Your doctor may choose different treatment options based on the severity of symptoms and the number of leaks present and your general medical conditions.
Medical treatment for paravalvular leaks is a palliative measure. Treatment plan includes dealing with symptoms of heart failure. Diuretics (water pill)and medication to reduce the blood pressure are used to treat symptoms and reduce the workload on the heart. If haemolysis is present, iron and folate supplementation may be required. If the hemoglobin level is severely reduced, erythropoietin injections and repeated blood transfusions may be given to maintain appropriate hemoglobin levels
Open Heart Surgery
Until several years ago, surgery was the only available option for your PVL. During surgery, your valve is either repaired or replaced. Surgical correction involves either repair of the leak or re-replacement of the valve with a bioprosthetic valve. This depends on the findings at surgery, condition of the native annulus (ring), location and size of the leak, and surgical exposure. Many techniques can be used to repair the paravalvular leak from suturing to patch closure
Although your PVL may be treated with open-heart surgery, the risk of this procedure is usually greater than the original operation and will require a lengthy time to recover.
Percutaneous/ Transcatheter Therapy
Percutaneous closure is a minimally invasive, non-surgical closure of the Paravalvular leak. The procedure is typically performed in the cardiac catheterization laboratory under general anesthesia. It is a procedure of last resort when surgery is too high risk or thought to be unfavourable by an experienced valve surgeon.
For mitral leaks, the doctor will insert a catheter into the femoral vein in the groin. Once asleep, a TEE probe is inserted. Your doctor inserts the catheter and the device by using x-ray and ultrasound (TEE) guidance. The doctor will use a special flexible tube to hunt for the leak with a wire. A long needle is used to puncture the atrial septum. Once the wire crosses the leak, a large catheter will be advanced to deliver a device that will block the hole. Once the device is in position, it is released from the catheter and seals off your PVL. The device acts as a plug to stop the leak.
In rare cases, instead of femoral access (inserting a catheter through your groin), the doctor may use an apical approach which involves placing a catheter into the left side of the heart through the chest wall using a very small incision.
Based on the investigation, your doctor will discuss with you the best treatment option for you.
Paravalvular leak closure is not perfect. Procedures can be long and difficult, and sometimes it may be impossible to close the leak at all. Sometimes, even in failure, it is thought a second attempt might be helpful and may be offered.
Long Term Health Implications
Small paravalvular leaks are usually well tolerated. If the PVL becomes more severe, then this can cause the pressure in your heart and lungs to increase. Over time this can lead to symptoms and signs of heart failure.
Small paravalvular leaks may also cause hemolytic anemia. The leaking of the blood between the natural heart tissue and prosthetic valve can lead to destruction of red blood cells which reduces the blood count and sometimes require treatment with blood transfusions.
If you have been diagnosed with a paravalvular leak and have not developed symptoms, you should still have regular follow up with your cardiologist to monitor your heart function and available treatment.
For aortic paravalvular leaks, the doctor will get access to the femoral artery and pass a catheter over the aortic arch. A catheter wire will be used to hunt for the leak. Once the wire is across we will use it to deliver a closure device.
Frequently Asked Questions
Are there any lifestyle restrictions following paravalvular leak closure?
In general there are no lifestyle restrictions following paravalvular leak closure, but usually, people who have this procedure have been ill for some time, so caution must be taken.
Will I need any further treatments following treatment?
Your cardiologist will provide full written guidelines in terms of activities and medications. It is important to follow these guidelines and adhere to the prescriptions. A follow-up appointment will be scheduled 2-3 months post procedure to ensure a safe and smooth recovery. At that visit, you will have an echocardiogram to monitor the device that has been placed and the progress your heart has made in returning to normal. Your doctor will decide at this time whether you should return to your own doctor for follow up of whether further follow up is required.
Will OHIP (public insurance) cover my procedure?
Yes. OHIP fully covers the cost of the procedure.
How urgent is the treatment?
Once you are symptomatic, it is advisable to receive medical treatment as soon as possible.
Who is a candidate for PVL Closure in Ontario?
A patient who is inoperable or at high risk for open-heart surgery. Usually decisions are made in collaboration with a patients surgeon.
What are the chances that the Device implantation will fail?
Minimally invasive percutaneous device closure of paravalvular leaks is an effective treatment. Occasionally, due to the complex nature of the leak(s), device therapy may not be possible. In those cases, the patient will need to be referred for surgical repair or treated with medications if surgery is not possible or feasible.