Percutaneous insertion of a closure device to repair a paravalvular leak around a replaced mitral or aortic valve

Paravalvular leak is a complication after surgical or transcatheter replacement of a mitral or aortic valve. Most leaks are not significant, but some leaks may lead to heart failure or haemolytic anaemia.

Current treatments include a second surgical procedure to replace the malfunctioning valve or a valve-in-valve transcatheter aortic valve insertion.

The procedure is done using a combination of local anaesthetic and sedation, or general anaesthesia. The exact technique varies according to the type of leak being repaired.

For mitral valves, an antegrade transseptal approach is most commonly used. In this approach, transseptal left atrial catheterisation is done under imaging guidance using standard techniques. A guidewire may be used to cross the leak. A delivery sheath is then passed from the venous access and 1 or more closure devices are deployed to close the leak. Transoesophageal echocardiography is used to confirm adequate reduction of peri‑mitral regurgitation and fluoroscopy is used to confirm normal mechanical prosthetic leaflet motion before closure device release.

For aortic valves, a retrograde approach is usually used. Transthoracic echocardiography may be enough to image the leak, but for posterior leaks, transoesophageal echocardiography or intracardiac echocardiography may be needed. The leak is usually crossed using a guidewire over a catheter. After crossing, the guidewire is exchanged for a stiffer wire and a delivery sheath is advanced to deploy the closure device.

More than 1 device may be needed to adequately close the leak.