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Most PVLs are hemodynamically non-significant, however large leaks lead to heart failure and increased risk of infectious endocarditis.

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Intravascular hemolysis causing anemia is also common in small PVLs. In many patients reoperation is associated with very high risk and alternative methods using transcatheter closure have been designed.

Such techniques are less invasive and can be used in most of high-risk patients. Paravalvular or paraprosthetic leak PVL is a complication associated with the implantation of a prosthetic heart valve whether traditional surgical or a transcatheter TAVI approach.

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PVLs have so far most commonly been observed in patients surgically implanted with either bioprosthetic or mechanical valves. Paravalvular or paraprosthetic leak refers to blood flowing through a channel between the structure of the implanted valve and cardiac tissue as a result of a lack of appropriate sealing.

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The majority of PVL are crescent, oval or roundish-shaped and their track can be parallel, perpendicular or serpiginous. Of note however, this apparently high incidence was reported in studies using transesophageal echocardiography TEE which is able to also detect small, non-significant jets.

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Etiology and mechanism of aberrant paraprosthetic flow PVL is most commonly related to disruption of sewing ring sutures precipitated by infectious endocarditis accompanied by an abscess formation or significant calcification and fibrotic scar of the annulus. Technical factors during the surgical procedure may also play a role.

They may result in incomplete apposition of the valvular structure against the annulus leading to formation of single or multiple jets located externally to the sewing ring. In most cases, paravalvular flow is present immediately after valve implantation but is mild and causes no symptoms [].

Hemolysis can be severe enough to precipitate symptoms of anemia or they can also be mild. In latter cases, asymptomatic hemolysis is diagnosed based on reduced hemoglobin levels, elevated lactate dehydrogenase activity LDHchanged reticulocyte counts and bilirubin levels, as well as reduced haptoglobin concentrations [5] [6].

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Although natriuretic peptides measurements are not commonly conducted in studies investigating PLVs, our registry showed that the majority of patients with significant PVL present with elevated levels of N-terminal pro-B-type natriuretic peptides NT-proBNP. Sucessful imaging of the PVL can be challenging.

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Transthoracic echocardiography TTE often cannot differentiate the PVL from prosthetic regurgitation which is a result of degenerative changes of bioprosthetic valve or pannus ingrowth in the mechanical valve. In such a situation, TEE is crucial and often requires multiple projections.

The challenges of echocardiography in thes datings site leak jet area are related to the presence of thrombi, pericardial fluid, artifacts and acoustic shadows caused by the structure of the prosthetic valves [4]. Echocardiographic evaluation of PVL should provide the following information: Shape and orientation of the jet Number of jets Presence of the distal flow reversal.

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