What is the management of a paraprosthetic leak after Double Valve Replacement (DVR)?

Management of Paraprosthetic Leak After Double Valve Replacement (DVR)

Surgical intervention is recommended as first-line therapy for patients with intractable hemolysis or heart failure symptoms due to paraprosthetic leak following DVR, unless surgical risk is high or prohibitive. 1

Diagnosis of Paraprosthetic Leak

Proper diagnosis is essential before determining management:

• Imaging studies:

  • TTE and TEE are recommended to determine the cause and severity of the leak, assess ventricular function, and estimate pulmonary artery systolic pressure 1
  • 3D TEE is particularly valuable for precise assessment of:
    • Location of defect(s)
    • Dimensions of the leak
    • Orientation relative to the sewing ring and prosthetic valve components
    • Relationship to subvalvular structures 1

• Clinical presentation may include:

  • Asymptomatic detection during routine follow-up
  • New heart murmur or change in prosthetic valve sounds
  • Heart failure symptoms
  • Hemolytic anemia (with or without symptoms) 1

Management Algorithm

1. Symptomatic Patients

For patients with intractable hemolysis or heart failure:

• Low to moderate surgical risk:

  • Surgical intervention is the recommended first-line therapy 1
  • Options include:
    • Repair of the paravalvular defect
    • Replacement of the prosthetic valve

• High or prohibitive surgical risk:

  • For bioprosthetic valves: Transcatheter valve-in-valve (ViV) procedure at a Comprehensive Valve Center 1
  • For mechanical or bioprosthetic valves with suitable anatomy: Percutaneous paravalvular leak closure at a Comprehensive Valve Center 1

2. Asymptomatic Patients

• With severe prosthetic regurgitation and low operative risk:

  • Surgical intervention is reasonable due to risk of sudden clinical deterioration 1

• With mild to moderate regurgitation:

  • Close monitoring with serial echocardiography
  • Medical management as needed

Medical Management

For patients with hemolytic anemia due to paravalvular leak:

• Folic acid and iron supplementation
• Periodic blood transfusions if needed
• Consider intervention if anemia becomes intractable 1

Special Considerations

1. Rule out endocarditis:

   • New paravalvular leak late after valve implantation raises concern for infective endocarditis
   • Requires blood cultures and appropriate imaging
   • If present, requires antibiotic treatment before surgical therapy
   • Endocarditis is a contraindication to transcatheter therapy 1

2. Surgical considerations:

   • Mortality rates are higher for reoperations compared to initial valve surgery
   • Operative mortality rates vary by valve position:
     • 3% for isolated aortic valve procedures
     • 8% for mitral valve procedures
     • 14% for double valve procedures 1

3. Percutaneous closure considerations:

   • Success rates are variable (approximately 70-77%)
   • Residual regurgitation affects outcomes - mild or less residual leak is associated with better survival 1
   • Requires specialized expertise at a Comprehensive Valve Center

Common Pitfalls to Avoid

1. Inadequate imaging assessment:

   • TTE alone is insufficient, especially for mitral prosthetic valves
   • TEE is essential to distinguish transvalvular from paravalvular leaks 1

2. Delayed intervention:

   • Waiting too long in symptomatic patients can lead to irreversible ventricular dysfunction
   • Bioprosthetic valve regurgitation can progress rapidly 1

3. Missing concurrent endocarditis:

   • Always rule out infection before planning intervention

4. Underestimating surgical risk:

   • Reoperation carries higher risk than initial valve surgery
   • Risk is particularly elevated for mitral and double valve procedures 1

Paraprosthetic leaks following DVR require careful evaluation and a structured approach to management based on symptoms, surgical risk, and valve type. Early referral to a Comprehensive Valve Center is recommended for optimal outcomes.