Signs of Paravalvular Leak
Paravalvular leak (PVL) presents with specific clinical and imaging findings including heart failure symptoms, hemolytic anemia, and characteristic regurgitant jets on echocardiography that occur outside the normal valve closure line. 1, 2
Clinical Manifestations
Symptoms
- Shortness of breath/dyspnea
- Fatigue
- Exercise intolerance
- Symptoms of heart failure (edema, orthopnea)
- Palpitations
Physical Examination Findings
- New or changed heart murmur
- Change in prosthetic valve sounds
- Signs of heart failure (pulmonary rales, peripheral edema, elevated JVP)
- Pallor (if significant hemolysis is present)
- Jaundice (in cases of severe hemolysis)
Laboratory Findings
- Hemolytic anemia
- Decreased hemoglobin and hematocrit
- Elevated lactate dehydrogenase (LDH)
- Decreased haptoglobin
- Elevated indirect bilirubin
- Presence of schistocytes on peripheral blood smear
Imaging Findings
Transthoracic Echocardiography (TTE)
- Regurgitant jet outside the prosthetic valve sewing ring
- Color Doppler showing abnormal flow patterns around the valve
- May underestimate severity, particularly for mitral prostheses due to acoustic shadowing 1
Transesophageal Echocardiography (TEE)
- Superior to TTE for detecting and localizing PVL
- Better visualization of regurgitant jets
- Can determine circumferential extent of leak
- Low-esophageal four-chamber view with rotation to two- and three-chamber views is optimal for mitral PVL
- Transgastric short-axis view useful for imaging entire circumference of valve/sewing ring 1
3D Echocardiography
- Ideal for imaging the entire prosthesis and sewing ring
- Provides precise assessment of defect location and dimensions
- Shows extent of paravalvular regurgitation
- Helps determine relationship to subvalvular structures 1, 2
Cardiac CT
- Can detect contrast-enhanced blood around the valve in continuity with cardiac chambers
- Useful when echocardiographic images are limited by acoustic shadowing
- Provides optimal fluoroscopic angles for planning transcatheter treatment
- May miss smaller PVLs due to lack of flow information 1
Cardiac MRI
- Valuable for quantification of regurgitant volume
- Useful when other imaging modalities show discordant results 3
Location Patterns
- Mitral valve dehiscence occurs mainly in posterior or lateral region, rarely anteriorly 1
- Aortic PVLs may occur at any position around the annulus
- Multiple PVLs can occur simultaneously
Severity Assessment
- Mild: Small, localized jet with minimal hemodynamic impact
- Moderate: Larger jet with some hemodynamic consequences
- Severe: Extensive regurgitation with significant hemodynamic compromise
Differential Diagnosis
- Transvalvular regurgitation due to prosthetic valve dysfunction
- Suture pledgets (can mimic small PVLs on imaging)
- Prosthetic valve endocarditis (may present with PVL)
- Native valve regurgitation of another valve
Clinical Pitfalls
- PVLs may be missed on routine TTE, especially with mitral prostheses
- New PVL late after valve implantation should raise suspicion for endocarditis
- Hemolysis may occur even with relatively small PVLs
- Multiple imaging modalities may be needed for accurate assessment
- Severity of symptoms may not correlate with size of leak 1, 2
Early detection and accurate assessment of paravalvular leaks are crucial for appropriate management decisions, as significant PVLs can lead to heart failure, hemolysis requiring transfusions, and increased risk of endocarditis.