Paravalvular Aortic Leak After Transcatheter Aortic Valve Replacement: Current Knowledge

Perspective:

The following are 10 points to remember about these techniques:

1. Transcatheter aortic valve replacement (TAVR) is now well-established as the standard of care for patients with severe symptomatic aortic stenosis who are deemed inoperable, and is seen as an alternative treatment option to surgical aortic valve replacement (SAVR) in a subset of patients with high postoperative mortality.

2. Paravalvular leak (PVL) is a complication only of aortic valve prostheses, and occurs more commonly post-TAVR than after SAVR.

3. The overall incidence of PVL post-TAVR ranges between 50% and 85%, which is significantly higher than what has been observed in SAVR, reported between 1% and 47.6%, with only 4.2% consisting of more than mild PVL.

4. Moderate to severe PVL is an independent predictor of mortality in the postoperative period to 30 days, at 1 year, and at 2 years.

5. Clinical characteristics associated, such as male sex, New York Heart Association functional class IV, and no previous aortic valve replacement, have been suggested to be predictive of PVL.

6. In quantifying PVL, a comprehensive integrated approach must always be used. The American Society of Echocardiography criteria for assessing PVL severity by echocardiography have emphasized describing the jet anatomy (i.e., location, circumferential extent, and width), particularly when visualized by color Doppler in the aortic short-axis view.

7. The pathophysiologic consequences of acute valvular regurgitation occurring after valve deployment, as well as the clinical impact of chronic moderate-severe PVL, warrant early and effective remediation to avoid conversion to open surgery as well as to prevent progression into heart failure.

8. Acute valvular regurgitation resulting from initial malpositioning of the transcatheter heart valve has been remediated successfully by either refolding and reinserting the valve, or repositioning of the valve using the snare technique. Occluders have been used successfully in treating chronic PVL post-TAVR, but needs further study.

9. The risks and impact of PVL can be mitigated by careful preprocedural imaging and device selection, standardization of procedural techniques and imaging, prompt recognition and accurate characterization of acute PVL, and long-term surveillance, prevention, and management of PVL.

10. As the use of TAVR expands to lower risk groups, the need to address PVL by further refinement and development of transcatheter heart valve technology is essential to ensure a favorable risk–benefit ratio for the patient.

Clinical Topics: Cardiac Surgery, Congenital Heart Disease and Pediatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and CHD and Pediatrics, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Sleep Apnea

Keywords: Odds Ratio, Infant, Newborn, Leukomalacia, Periventricular, Standard of Care, Diagnostic Imaging, Heart Valve Prosthesis Implantation, Angioplasty, Balloon, Coronary, Postoperative Period, Echocardiography, Doppler, Bioprosthesis, Recognition (Psychology), Reference Standards, Heart Failure, Heart Valve Diseases, Conversion to Open Surgery, Risk Assessment, Infant, Premature, United States


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