Transesophageal Echocardiography (TEE)-Guided Paravalvular Leak (PVL) Closure: Expanding Horizons Beyond Operating Room

Abstract

Paravalvular leak (PVL) is a common, yet challenging entity occurring due to dehiscence of the annular tissue around the prosthetic valve, resulting in regurgitation of blood retrogradely. Although any prosthetic valve can be subjected to the risk of developing PVL, it is most commonly reported with the mitral valve followed by the aortic valve. The incidence of mitral PVL is around 7 to 17%, whereas with the aortic valve it is 5 to 10%. Symptomology can vary from asymptomatic patients with mild PVL to disabling symptoms pertaining to heart failure and hemolysis. TEE plays a pivotal role in the overall assessment along with procedural guidance for their closure. Multiple two-dimensional (2D) imaging views are required to scan the entire sewing ring diameter of a prosthetic valve. Three-dimensional (3D) TEE can give crucial information such as the number, size, shape, and circumference of the defects. 3D mitral en face view can give anatomical localization of the defect. During the procedure, TEE can assist in the confirmation of the position of the guidewire through the defect and not through the prosthetic valve. It also helps to conform to the adequate positioning of the vascular plug device and unrestrictive movement of the native prosthetic heart valve. TEE when combined with fluoroscopy can help in real-time guidance of passage of the guidewire and transcatheter device in relation to the prosthetic valve. Recently, Ahmed et al have named this technology as “Fusion Technique,” where they have combined real-time 2D and 3D TEE with fluoroscopy to facilitate the closure of PVL. Now that the time of minimally invasive surgery has taken over conventional surgery and fast tracking and enhanced recovery after surgery (ERAS) is the need of the moment, percutaneous PVL closure is preferred over surgical PVL closure. A study done by Gakrinho et al showed that percutaneous PVL closure has a reasonable success rate along with a low complication rate and the results are comparable to surgical treatment in high-risk patients. We hereby share our experience of the successful closure of PVL via the transcatheter technique using various 2D and 3D techniques.