What is paravalvular leak (PVL)?
Paravalvular leak (PVL) is a condition in which blood leaks through a hole formed at the edge of the valves in some patients who have an artificial valve or ring in their heart. This hole usually occurs due to wear and tear. If the amount of blood leakage is significant, a portion of the blood that should be sent to the body cannot be delivered. This leads to the development of heart failure symptoms (shortness of breath, fatigue, palpitations, etc.). Sometimes, even if the amount of leakage is small, blood destruction (hemolytic anemia) occurs as a result of blood cells rapidly hitting the heart walls and rupturing. This manifests itself with symptoms related to anemia. In this type of anemia, a frequent need for blood transfusions may arise. Some small leaks, however, do not cause any problems and therefore do not require treatment.
What causes paravalvular regurgitation?
Although there can be many causes, the most common reasons are: wear and tear (degeneration) at the sutured area—especially due to calcification—infection (infective endocarditis), and inadequate surgical technique. PVL can occur at any time after heart surgery (days, weeks, months, or even years later). In fact, PVL can occur not only with artificial valves implanted surgically but also with artificial valves implanted via non-surgical methods (TAVI).What is PVL closure?
One of the treatment options for PVL is to undergo heart surgery again. In surgery, usually, the old artificial valve is removed and a new one is implanted. However, undergoing surgery for a second time is riskier compared to the first operation. With the advancement of technology, treating PVL with a non-surgical method has now become possible. This method is called “PVL closure.” The hole causing the leak is closed with the help of a plug. This plug is advanced to the heart through the leg (groin) vein inside a long, thin, flexible tube (catheter). The reason the term “non-surgical” is used is that, unlike surgery, the procedure is performed without stopping the heart and without cutting the rib cage. Non-surgical PVL closure provides the following benefits compared to surgery:
- Lower risk (death, stroke, infection, etc.)
- Less pain
- Less stress
- Faster recovery
- Shorter hospital stay
- Better cosmetic appearance (no incision scar on the chest)
Is the PVL closure procedure an effective method?
With the development of non-surgical methods, it is now possible to treat a greater number of patients. In follow-up visits, three out of every four patients reported that their symptoms had disappeared or significantly decreased. In cases where success cannot be achieved, surgery is necessary.
Who performs the PVL shutdown procedure?
The procedure is performed by interventional cardiologists. An imaging cardiologist also obtains various images via ECHO (TEE) performed through the patient’s esophagus and guides the interventional cardiologist.How long does the PVL shutdown process take?
Most procedures take 2–3 hours. This duration may be shorter or longer depending on the specifics of the case and the patient’s anatomy.
What should people who have undergone a PVL procedure be aware of?
- Competitive or strenuous sports should be avoided for the first month after PVL closure.
- Microorganisms entering the bloodstream can directly contaminate the device or the artificial heart valve via the blood, leading to a serious infection called infective endocarditis. Therefore, lifelong antibiotic prophylaxis is recommended immediately before bloody procedures, such as tooth extraction or surgery on another organ.
- Due to the metallic nature of these devices made of nickel-titanium alloy, it is often assumed they will be affected by the magnetic field of an MRI. However, these devices and artificial heart valves have weak magnetic susceptibility; therefore, there is no harm in undergoing an MRI, including 3 Tesla.
References
- Otto CM, Nishimura RA, Bonow RO, et al. ACC/AHA Guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2021 Feb 2;77(4):e25-e197.
- Vahanian A, Beyersdorf F, Praz F, et al. ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2022;43(7):561-632.
- Lasala JM, Rogers JH, eds. Interventional procedures for structural heart disease. Philadelphia PA: Elsevier; 2014.